Roger Leadbeater

GREATER MANCHESTER

b POLICE

Chief Constable

Ms Tanyka Rawden

His Majesty’s Senior Coroner for South Yorkshire (West)
Office of HM Coroner,

The Medico-Legal Centre,

Watery Street,

Sheffield,

S3 7ES

16" March 2026

Dear Ms Rawden,
RE: Regulation 28 Report

Thank you for your correspondence dated 27" January 2026 regarding the tragic
death of Mr Roger Leadbeater. Greater Manchester Police (GMP) acknowledge the
concerns raised and extends its deepest sympathies to Mr Leadbeater’s’ family.

GMP strives to provide the best possible service to members of the public. Where
issues are identified which require action to be taken to improve the service we
provide, | am committed to ensuring that the force makes appropriate changes.

This letter will set out the immediate steps that have been taken to address the
concerns raised and it will also explain the steps that GMP will continue to take to
embed into daily practice the changes that have already been implemented.

Concerns Highlighted

The inquest heard evidence that there was a lack of a clear, documented process to
record information sharing when officers were involved in the handover of individuals
between Police forces and between Police forces and hospitals. The court expressed
concern that without a robust handover process in place, key information about those
detained under the Mental Health Act who were transported by police will not be
appropriately communicated which in turn may affect subsequent risk assessments
and decisions taken in respect of patient leave.

On 22 January 2026 the Court was told that GMP has a handover form, but the
relevant policies had not been updated to support its implementation or audit its use.

Actions and Planned Response

GMP recognises the importance of learning from the circumstances of this case and
has implemented a series of measures to address the concerns raised by the coroner.

| set out below the steps that have been taken by the force.
(1) Amended Form 1157

GMP utilises Form 1157 (Mental Health and Monitoring Form) to record information
when officers are deployed to deal with individuals presenting with mental health
concerns. At the time of Mr Leadbeater’s death, the form was mandated for
completion in the following circumstances:

e When officers exercised their powers under Section 136 of the Mental Health
Act 1983 (MHA)

e When a Section 135 MHA warrant was executed

e When officers assisted with the voluntary attendance at hospital with an
individual for a mental health concern

e Where an officer was the decision-maker in a Mental Capacity Act 2005 (MCA)
encounter with an individual

In Mr Leadbeater’s case, the individual being conveyed was subject to detention under
Section 2 MHA and as such Form 1157 was not mandated for completion by the
officers involved in the transfer and handover. As the coroner identified, this placed a
reliance on individual officers providing relevant information at the point of handover
with no structure in place to trigger, or document, that process.

To address the issues that presented in Mr Leadbeater’s case, GMP has amended
Form 1157 and moreover extended the circumstances in which the form is mandated
for completion. The form must now be completed whenever officers take or convey (or
assist in conveying) a person to hospital under any of the following circumstances:

When officers utilise the following MHA powers:

e Section 2 — when police assist in conveying a person liable to be detained — by
exception as the hospital should ordinarily arrange transport

e Section 18 — return of an absconded patient — by exception as the hospital
should ordinarily arrange transport

e Section 135(1) or 135(2) — where a warrant is executed to facilitate the
assessment or return of a detained patient.

e Section 136 — removal to a place of safety from a public place.

Any other MHA detention, including:

e Section 3 (treatment)

e By exception, transfers between hospitals/prisons at the request of NHS
partners/Courts and ratified by Force Critical Incident Commander or Duty
Police Superintendent

MCA Powers:

e When Police or the Ambulance Service are the MCA decision maker and
officers accompany someone for their safety.

Voluntary Mental Health Attendance:

e When officers convey a voluntary patient due to risk or vulnerability.

Missing Persons from Mental Health Units:

e When Police locate or return to hospital any person missing from a mental
health unit, whether detained or voluntary.
e This includes:
o Individuals missing from Sections 2, 3, 4 or Section 17 leave failures
o Missing voluntary patients
o Section 17 MHA returned patients

Section 6 of the amended Form 1157 requires officers to identify the presence (or
absence) of a number of key risk factors and relevant history. Where a risk factor or
relevant history is present the form requires detail of that to be provided. At the point
of handover, a copy of the form is provided to the receiving agency.

The effect of this change will be that whenever a person is conveyed by GMP officers
in any of the circumstances outlined above, a form will require completing which
documents relevant information known about that individual. This process creates an
obligation on officers at handover and removes the reliance on individual officers
proactively providing information.

These changes have been reflected in amendments to GMP’s Mental Ill Health, Mental
Incapacity & Learning Disabilities Policy & Procedure.

(2) Communication of Changes

The immediate changes implemented by GMP required a series of measures to be
taken to bring the changes to the attention of officers who would be likely to be involved
in the conveyance of individuals with mental health needs. The following steps were
taken to ensure awareness across the force:

e Intranet Article

On 23'4 January 2026 the amended Form 1157 and the extended circumstances in
which it is to be used was the subject of an article on the landing page of GMP’s
intranet. All officers and staff accessing the force intranet were met with the article as
a news story. The intranet article explained the changes and directed readers to the
Mental Ill Health, Mental Incapacity & Learning Disabilities Policy & Procedure and the
specific amendments that had been made to that document to reflect the changes to
procedure set out above.

e Officer Briefings

The amended process was included as part of the morning briefing delivered to officers
at the start of their shifts. This briefing program was in place for a seven-day period
commencing on 20" January 2026. The program ran for seven days to ensure that it
captured all shifts across the force.

e Athoc Messaging

The Athoc system is the method GMP uses to deliver messages to mobile devices to
all its officers and staff. An Athoc message outlining the new process was delivered
across the force on Tuesday 20th and Wednesday 21% January 2026. Again, the
purpose of this messaging was to ensure that all officers received information about
the changed process and additional requirements in respect of the amended Form
1157.

e Chief Constable Orders

The Chief Constable issues orders on a weekly basis. All officers and staff are required
to read the orders as part of their duties. The amended form and process was included
in Chief Constable’s Orders published on Monday 26" January 2026.

The above steps represent the immediate action taken by GMP to undertake a force
wide awareness campaign to ensure that the widest possible audience received the
messaging in relation to the changed process.

To refresh the awareness campaign that took place in January 2026 the amended
Form 1157 process will be featured on the April 2026 newsletter published by GMP’s
Organisational Learning Hub. The newsletter highlights the top three learning points
for the month and is received by every police officer and staff member in GMP.

(3) 1157 Mobile App Update

To ensure the amended Form 1157 is fully embedded into frontline practice, GMP is
also updating the digital version of the form used on officers’ mobile devices. An initial
meeting to scope the required changes to the 1157 mobile app took place on 23
February 2026, during which the technical and operational requirements were agreed.
The final sign off for the project is due to take place on 16" March 2026 after which
development work will begin. It is estimated that it will take 3 months for the completion
of testing and for full release of the app to take place.

The updated app will replicate the revised structure of the new Form 1157 and will
include mandatory fields to ensure that officers capture all risk-critical information
before the form can be submitted. This enhancement will support greater consistency,
reduce the possibility of omissions, and further strengthen the reliability of information
provided to partner agencies at handover.

The Missing Person Safeguarding Unit within the Public Protection Division will run a
monthly report identifying all Missing Person episodes originating from hospitals. This
will be shared with the Prevention Hub to compare against their 1157 submissions via
the updated app, ensuring that the required documentation has been completed for
every relevant incident.

In addition, completion of the 1157 has now been incorporated into the new PRISM
app used by District Safeguarding Teams (MASH). Officers and staff triaging Care
Plans must confirm that the Form 1157 has been completed and attached before a
Care Plan can be closed. This creates a clear check-and-balance within the system
and prevents closure where the correct safeguarding paperwork has not been
provided.

(4) Training and CPD

GMP is embedding the learning arising from this case into its wider professional
development framework. The circumstances and lessons identified will be
incorporated into Missing Person Continual Professional Development (CPD),
ensuring that all officers receive consistent guidance on risk identification,
documentation and effective information sharing.

This learning will also be integrated into the Sergeants’, Inspectors’ and
Superintendents’ Skills Courses delivered to all newly promoted officers. In addition,
the Vulnerability CORE within the Public Protection Division is producing a short CPD
training video focused on mental health considerations in Missing Person cases. The
video will outline expectations around risk assessment, conveyance responsibilities,
and the structured handover of pertinent risk information to receiving hospitals,
including the completion of Form 1157.

Once complete, the video will be published on the Force Learning and Skills Hub,
accessible to all officers and staff, and supported by an intranet article to raise
awareness. The anticipated timescale for completion for this product is the end of
March 2026. It is also intended that this product will be incorporated into the training
for all new Student Officers joining GMP, supplementing their College of Policing
approved curriculum.

Embedding this learning within both CPD and core training will support long-term
cultural and behavioural change, strengthen professional curiosity, and reinforce the
importance of comprehensive information sharing when responding to vulnerable
individuals.

This will ensure that the revised expectations around risk identification,
documentation, conveyance responsibilities, and structured handovers are fully
understood across the workforce. Embedding the learning within CPD will support

long-term cultural and behavioural change and reinforce the importance of
comprehensive information sharing when dealing with vulnerable individuals.

GMP continually strives to improve its approach to public protection and is committed
to delivering the best service to the public. | hope the detail set out in this letter is
helpful in explaining the immediate and long-term changes that have been made by
GMP to address the issues identified in the case of Mr Leadbeater. The changes will
ensure that risk factors known to officers are documented and that the quality of
information sharing at the point of handover of those with mental health difficulties is
improved.

Yours sincerely,

Chief Constable

8th March 2026 

Dear Madam Coroner, 

Response to Regulation 28 report in respect of deceased Roger Gary LEADBEATER 

Thank you for your letter dated 27th January 2026 and the corresponding Regulation 28 
report where you raise one matter of concern. This matter is in relation to the arrangements 
for the physical handover of missing persons who are subsequently transferred to a medical 
facility or to another police force.  

South Yorkshire Police seek all opportunities to identify opportunities to learn and improve its 
response to those we serve. Whilst work had already been ongoing to improve this 
response, upon receipt of this Regulation 28 preventing future deaths notice I directed a 
thorough review around the actions of South Yorkshire Police.  

I wish to provide you with a detailed account of the actions we have taken to strengthen our 
procedures, the governance now in place to ensure compliance and the steps we are taking 
to support wider learning beyond this force. 

Implementation of the Revised Handover Process 

Several substantive measures have now been introduced: 

•  Dedicated Handover form — A new, purpose-designed form has been created to 

record the transfer of responsibility for a missing person. This form has been 
uploaded to the central repository on the Missing from Home (MFH) SharePoint 
portal to ensure universal accessibility and version control. 

•  System-Integrated prompts — A mandatory task has been embedded within 

Compact, our MFH management system. This provides officers with an automatic 
prompt at the relevant stage of the investigation and includes a direct link to the new 
form, reducing the risk of omission and ensuring a consistent workflow. 

•  Force-Wide communications — A comprehensive communication has been 

circulated across the organisation, outlining the new process, the rationale for its 
introduction and the tragic circumstances that brought the issue to light. This has 
ensured that all officers and staff understand both the procedural requirements and 
the moral imperative underpinning them. 

•  Governance-Level briefing — The thematic lead for MFH briefed the Missing 

Governance Meeting, comprising of Inspectors and Sergeants, to ensure that 
supervisory leaders are fully sighted on the new arrangements and are equipped to 
drive compliance at a local level. 

•  Tactical-Level briefing —Further briefings have been conducted at the tactical 

meeting attended by MFH officers. This has reinforced operational understanding 
and provided an opportunity for officers to seek clarification and raise practical 
considerations. 

 
 
 
 
 Assurance, Monitoring and Embedding 

To ensure that the revised process becomes fully embedded and consistently applied, the 
following assurance mechanisms have been established: 

•  MFH Officer quality assurance — as part of their existing responsibilities, MFH 
officers will review the Compact tasks associated with each case. Where the 
handover form has not been completed, they will escalate the matter in line with the 
established VA/VC escalation process. 

•  Supervisory review by Inspectors and Sergeants — supervisors will check the 
completion of the handover form during their routine review of MFH cases. This 
ensures that compliance is monitored at multiple levels and that any gaps are 
identified promptly. 

•  Audit of documentation quality — MFH officers will assess the quality and 

completeness of the information recorded on the form to ensure it meets the required 
standard and provides an accurate and reliable record of the handover. 

•  Structured Feedback Loop — ongoing feedback will be gathered from team leads 

and operational officers to identify any areas of misunderstanding, procedural friction, 
or opportunities for refinement. 

•  Governance Review — the revised process was reviewed at the governance 

meeting to confirm it is operating as intended and to agree any further improvements 
that may be necessary. 

National Learning 

Initial benchmarking undertaken by the force suggests this may represent a wider national 
gap in practice. In the interests of supporting broader learning and improving safeguarding 
arrangements across policing, the thematic lead has contacted the national Lead Staff 
Officer and will be presenting this work at a forthcoming national MFH quarterly meeting. 
The intention is to encourage consideration of this process as a potential model for national 
best practice. 

I hope this update provides reassurance that the force has taken the issues raised during the 
inquest with the utmost seriousness and has acted to address them. 

Yours faithfully  

Detective Chief Superintendent 

Head of Crime  

South Yorkshire Police