Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0517, written 15 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Oct 2025 |
|---|---|
| Reference | 2025-0517 |
| Deceased | Katie Overd |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Alcohol, drug and medication related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
lb 2 3 4 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer College of Policing Leamington Road Ryton-on-Dunsmore Coventry CV8 3EN 1. 2. RCRP Strategic Partnership Board Broadhurst House 1st floor, 56 Oxford Street Manchester M1 6EU CORONER I am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS I 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 27th March 2025 I commenced an investigation into the death of Katie Overd. The Inquest concluded on the 7th October 2025. The medical cause of Miss Overd’s death was due to : 1a) Fatal Combined Drug Toxicity 2) Ischaemic Heart Disease The conclusion of the Inquest was that the deceased died as a result of an unintended overdose of her prescribed medication on a background of longstanding inappropriate prescribing and lack of an attempted reduction of medication until 2020. CIRCUMSTANCES Miss Overd died on the 20th March 2025 at her home address. She was 46 years old. She had a complex medical history including chronic fatigue syndrome and fibromyalgia. She was unable to leave her first floor flat due to her mobility issues. All her shopping and medication was home delivered. The level of her care needs was not fully known as she was not open to any agencies save for her GP. All GP appointments were telephone appointments as she could not attend the surgery. Since approximately 2010, Miss Overd had developed an addiction to opioids, gabapentinoids and benzodiazepines due to years of inappropriate prescribing of very high doses. In 2020 a new GP began a reduction regime but this was extremely difficult given her then addiction. Miss Overd had contact with her family every day via telephone. She would not allow them entry into her property and after her death 100s of packets of medication were discovered in her home On the 19th March 2025 she had her daily evening call with her Mother. The following day her mother was not able to make contact with her daughter. She began telephoning her at 1pm and continued making approximately 30 calls before attending at her address at 7.30pm Her flat was locked with the key on the inside of the front door. As a first floor flat the family could not see into the flat. There was no doubt that Katie was inside her home as she was wheelchair/ housebound. At 20:31 the family made a telephone call was made to Greater Manchester Police. An initial question relating to whether their concern was a risk to life was not asked by the call handler. However there is no doubt family were expressing a concern for Katie’s life. At the end of this call they were advised to contact North West Ambulance Service (NWAS) as it was deemed to be a medical need. At 20:37 the family called NWAS and again explained the situation. At the end of this call they were advised that an ambulance would be deployed on a category 3 (within 2 hours, albeit on the night this would likely have been longer). Given the advice provided and the level of concern the family contacted a locksmith and gained entry to Katie’s home finding her deceased at 21:55 hours. It was clear from the articulate evidence given by the family that their understanding and belief of what to do in such a crisis was to contact emergency services who would respond quickly. In the first instance they were of the opinion they should ask for the police, this was due to both experience and a generally held public view. This meant they then had to repeat the same 7 minute call when advised to call NWAS. Ultimately whilst an ambulance would have been deployed it is clear for that any family in these circumstances they would likely have to wait for some hours for an ambulance as they are graded category 3. Once an ambulance had arrived at Katie’s property there would then have had to be a request to deploy the fire service to gain entry. The evidence was clear if the family had had any knowledge of the Right Care Right Person process they would have sought to obtain their own locksmith at 20:31 hours and gained entry to Katie's flat sooner. Whilst in this case there was no evidence this would have prevented Katie’s death, in other cases earlier entry into properties may save lives. 53. CORONER’S CONCERNS In my During the course of the investigation evidence revealed matters giving rise to concern. 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:- 1. There has been a decision made not to undertake any proactive public communications in relation to the implementation of Right Care Right Person. The court heard evidence this was both on a national and regional basis. As a result, the public who have significant concerns for the life of their family members may not seek assistance as quickly as they could do, labouring under the misapprehension that there will be a timely response from emergency services. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 9th December 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 and to the following Interested Persons namely The family of Katie Overd Greater Manchester Police North West Ambulance Service 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 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. 9 Date Signer
3 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.
Joanne Kearsley Senior Coroner for the Coroner area of Manchester North 9 December 2025 Dear Ms Kearsley Preventing Future Deaths Report – Katie Janette Overd Thank you for providing the College of Policing with a copy of your report dated 15th October 2025 following the death of Katie Overd. 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 in respect of proactive public communications relating to the implementation of the Right Care Right Person (RCRP) policy. 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 the College of Policing. When the NPA was originally developed and agreed by all the signatories, a discussion took place regarding whether there should be national public facing communications in respect of which agency should deliver specific services. However, it was agreed and remains the position that when the public make calls for service, they will not necessarily know which service is the most appropriate to be responding to a call as the nature of an incident and the associated risks can vary significantly. It is for this reason that the focus is on the public calling 999 when they believe they require an emergency service response and allow the pathways that have been agreed between agencies at a local level to then triage the call and make an informed decision as to which service is the most appropriate to respond to the specific incident. This is not unique to RCRP related calls and is a practice that is employed in other areas across policing and other agencies. In many areas there are localised agreements that have been developed, which need to be taken into account when decisions are being made. RCRP relates to decisions made within the control room about which is the most appropriate service and therefore this is an important step in the triage process across any agency that is contacted. 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. Together with our national partners in Health, we continue to monitor emerging themes and risks with a view to updating the published toolkit guidance as well as providing additional support and guidance directly to forces. We hope this provides reassurance 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 CC – Dupty Mayor of Greater Manchester
Joanne Kearsley
Senior Coroner for the Coroner area of Manchester North
Cc: Andy Marsh, College of Policing
Dear Ms Kearsley
RE: Regulation 28 Death of Katie Janette Overd
17 November 2025
I am writing in response to your email on 31 October regarding the Regulation 28 letter into the death of
Katie Janette Overd.
I have given further thought to your comment that NWAS would not have had powers of entry on arrival
at the property and hence that if NWAS attended they would have had to call GMFRS.
I have followed this up both with the Chief Fire Officer and senior officers in GMP and you are right that
this would be the case. This would likely have been different prior to Right Care: Right Person when
GMP would have likely forced entry to the property on attendance, though officers may not have been
able to deal with the medical needs that presented, and would have asked for NWAS attendance in that
case.
I therefore wanted to let you know that I will give further thought to this with the relevant agencies. For
a number of reasons, we are not sure that a public message that might lead to a family calling a
locksmith is the best response and so we wish to take the time to consider the various options that will
best meet the needs of the public. I will be happy to share our thinking with you in due course if you
wish.
I hope that’s helpful and thank you again for raising this with me.
Yours sincerely
Deputy Mayor of Greater Manchester
GMCA, Broadhurst House, 56 Oxford Street, Manchester, M1 6EU
Joanne Kearsley
Senior Coroner for the Coroner area of Manchester North
Cc:
, College of Policing
Dear Ms Kearsley
RE: Regulation 28 Death of Katie Janette Overd (ref: 25030828)
Thank you for sending me the Regulation 28 letter into the death of Katie Janette Overd.
30 October 2025
I will of course review the learning from this case and ensure that this is considered via the Right Care:
Right Person (RC:RP) Strategic Oversight Board that I chair.
Your report states that ‘if the family had known about the Right Care: Right Person process they would
have phoned the locksmith sooner’. However, Right Care: Right Person is not about whether an
emergency service will attend an incident, but rather which emergency service has the best skills to
respond to the call, irrespective of which service received it (the right care for the right person). RC:RP
is essentially an internal cross-service reorganisation process whereby pathways are agreed between
agencies on which service is best placed to respond to types of incidents following RC:RP principles.
GMP’s (and my) view is that a member of the public might not be sure which would be the most
appropriate emergency service to call, and so our processes are focussed on ensuring that the caller is
routed to the most appropriate service to respond, no matter where a call is received. We would rather
a member of public takes decisive action and calls “the emergency services” who can then, through
training and experience, identify the most appropriate service to meet their needs (as per RC:RP) ,
rather than delay contact whilst they ponder which service is the right one to respond to the specific
circumstances of their scenario – which itself may generate a delay. As you note, we have not
therefore focussed on external communication to suggest which service people should call initially, as
they should be directed to the right service via the call handler irrespective of which service they call.
Having said that, I recognise in this case that had they had knowledge and understanding of the RC:RP
process, that would have likely led to the family calling NWAS initially, which was the advice of the
GMP call handler gave when the call was received. In this instance, I believe the delay caused by
calling GMP and then calling NWAS was circa 7 minutes. I know that GMP have explored with NWAS
GMCA, Broadhurst House, 56 Oxford Street, Manchester, M1 6EU
on whether calls could be transferred directly between the two organisations but unfortunately it has not
been operationally practical to do so.
NWAS of course have their own triage system, which triages calls on receipt and identifies the
appropriate ambulance response category. You suggest that had the caller understood RC:RP, they
would have called a locksmith rather than the emergency services, but RC:RP would not have affected
that triage process. Unfortunately, there will always be the concern that a service could have responded
quicker and whether any delays may have negatively impacted upon outcome, but I’m afraid I can’t
comment on triage and response processes in NWAS.
All that said, I am keen to consider the learning from Ms Overd’s death and I will discuss the issue of
call transfer and external communications again with GMP, NWAS and our wider health and local
authority partners through the RC:RP Strategic Oversight Board.
Thank you for raising the case with me.
Yours sincerely
Deputy Mayor of Greater Manchester
GMCA, Broadhurst House, 56 Oxford Street, Manchester, M1 6EU
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