Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0175, written 15 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Mar 2026 |
|---|---|
| Reference | 2026-0175 |
| Deceased | Ruslans Burkevics |
| Coroner | Michael Pemberton |
| Coroner area | Manchester (West) |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Chief Constable Greater Manchester Police 1 I CORONER I am Michael James PEMBERTON, Area Coroner for the coroner area of Manchester West 2 I CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investi:::iations) Regulations 2013. 3 I INVESTIGATION and INQUEST On 10 January 2025 I commenced an Investigation into the death of Ruslans BURKEVICS aged 33. The investigation concluded at the end of the inquest on 06 March 2026. The conclusion of the inquest was a narrative that: Ruslans Burkevics died as a consequence of multiple injuries sustained in a fall from height, the exact circumstances of which were not directly witnessed and cannot be ascertained on the available evidence. The medical cause of death was Multiple injuries. 4 I CIRCUMSTANCES OF THE DEATH Ruslans Burkevics died on 7th January 2025 at Royal Albert Edward Infirmary Wigan, after being found outside his home address Flat 75 Boyswell House, Wigan with multiple injuries having likely experienced an unwitnessed fall from an open 12th floor bedroom window. He had a history of self-harm and drug induced psychosis, but there was insufficient evidence to determine the precise circumstances of the fall from height. He had contact with officers from Greater Manchester Police the evening before he was discovered on the ground outside an open window of his flat. He had been escorted home by officers with his agreement after being reported to have been running into traffic in the locality. He was taken to his flat at around 22: 55 on the 6th January 2025. 5 I CORONER'S CONCERNS During the course of the investigation my inquiries 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 course of evidence it was heard that the deceased had contact with officers from Greater Manchester Police on the night before he was found having apparently suffered a fall from height outside his home address. There was no causative or contributory link established on the evidence and officers actions the previous evening were appropriate. Regulation 28 - After Inquest Document Temolate Uodated 30/07/2021 2 - The deceased had a history of mental health difficulties and use of substances which contributed to episodes of mental health crisis. Police had on other occasions utilised powers under the Mental Health Act to bring him to a safe place where his mental health needs could be assessed. 3 - It was reflected in evidence that whilst front line officers must receive regular refresher training on first aid, no such provision for mental health first aid training is currently being provided, on a regular and refreshing basis. There was evidence that no direct training on mental health is provided apart from initial training. Mental Health may be a topic within other qualifications and development courses as a peripheral issue of that subject, but no dedicated mental health first aid type refresher is provided at present. 6 I ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 I YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 01, 2026. I, the coroner, may extrnd 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. 8 I COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Greater Manchester Mental Health I have also sent it to National Police Chiefs Council who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 15/03/2026 Michael James PEMBERTON Regulation 28 - After Inquest Document Template Updated 30/07/2021 Area Coroner for Manchester West I Regulation 28 - After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Constable Mr Michael Pemberton HM Assistant Area Coroner for Manchester West HM Coroners office Paderborn House Bolton BL1 1QY Sent via email 1st May 2026 Dear Mr Pemberton Regulation 28 report following the inquest touching the death of Mr Ruslan Burkevics Thank you for your report dated the 15th March 2026 arising out of the inquest touching upon the tragic death of Mr Ruslan Burkevics. Greater Manchester Police (GMP) acknowledges the concerns raised and extends its deepest sympathy to Mr Burkevics’ family, Having carefully considered the concerns set out within your report, and acknowledging your findings as set our therein, I reply as follows: Issues Highlighted: 1 – During the course of evidence it was heard that the deceased had contact with officers from GMP on the night before he was found having apparently suffered a fall from height outside his home address. There was no causative or contributory link established on the evidence and officers actions the previous evening were appropriate. 2 – The deceased had a history of mental health difficulties and use of substances which contributed to episodes of the mental health crisis. Police had on other occasions utilised powers under the Mental Health Act to bring him to a safe place where his mental health needs could be assessed. 3 – It was reflected in evidence that whilst front line officers must receive regular refresher training on first aid, no such provision for mental health first aid training is currently being provided, on a regular and refreshing basis. There was evidence that no direct training on mental health is provided apart from initial training. Mental Health may be a topic within other qualifications and development courses as a peripheral issue of that subject, but no dedicated mental health first aid type refresher is provided at present. GMP’s response Thank you for raising these matters of concern relating to Mr Burkevics. GMP recognise the critical role that effective, up-to-date mental health training plays in ensuring officers are equipped to respond appropriately to members of the public who are experiencing mental health crisis. I welcome the opportunity to outline the steps already underway to address the concern regarding the absence of a structured and refreshed programme of mental health-specific training for frontline officers. As part of our organisational development under the post-Right Care Right Person operating model, GMP’s mental health portfolio underwent a change of strategic ownership in March 2026. This transition has initiated a comprehensive review and refresh of the entire portfolio to ensure that our approach to policing mental health-related demand is consistent, professional and aligned to modern policing standards. This work is intended to strengthen the organisation’s capability to manage increasingly complex and high-risk situations involving mental ill-health. In recognition of the need for improved and better-structured mental health training, an initial review of existing provision commenced in October 2025. Building upon that early assessment, a formal commissioning request was initiated in March 2026 with our internal training department to undertake a full and detailed evaluation of current training products, delivery methods and organisational requirements. Crucially, this programme of work will be informed by the professional experience of frontline officers who frequently encounter mental health-related incidents. GMP will also be engaging with key partners across the mental health, health and local authority sectors to ensure that future training reflects shared learning, best practice, and the complex, multi-agency nature of supporting individuals in crisis. This includes obtaining feedback on operational challenges, gaps in knowledge, and emerging themes in mental health need across Greater Manchester. The overarching aim of this refreshed training approach is to ensure that all GMP officers receive appropriate, relevant and contemporary input that enhances their understanding of mental health vulnerabilities, improves their confidence in managing crisis situations, and ultimately strengthens the safety and safeguarding of the public. This includes exploring opportunities to introduce a dedicated mental health first-aid refresher product delivered on a cyclical basis, complementing existing first-aid requirements and ensuring officers remain informed in an area where societal needs and clinical understanding continue to evolve. First aid training in policing is predominantly skills-based and focused on managing physical injury or medical emergencies, such as haemorrhage control, resuscitation and immediate life-saving intervention. These competencies are maintained through regular refreshers to ensure operational competence is maintained. Mental health first aid differs significantly in both purpose and scope and is not necessarily focused on time-limited technical intervention. It focuses on the early identification and handling of mental health crises and informed decision-making in complex, often evolving situations. This includes understanding risk factors, legal thresholds, statutory powers, and the proportionate use of police authority under mental health and capacity legislation. In addition to this ongoing review of mental health first aid provision, it is important to note that GMP officers are not mental health professionals but lay persons operating within a policing context. As part of their existing training and operational guidance, officers are explicitly directed to seek specialist mental health advice through the Mental Health Urgent Triage (MHUT) service when incidents involve elements of mental ill health. MHUT provides officers with access to qualified mental health professionals who are able to offer expert advice, supported by access to relevant patient records and the wider health system, thereby informing proportionate and lawful decision making. Officers have been reminded of the availability and purpose of MHUT through multiple internal communication channels, including targeted internal messaging sent directly to officers’ mobile devices, organisational emails, posters, and briefings delivered through intranet and team-based forums. These measures ensure that, notwithstanding the current review of mental health first aid training, officers remain aware of the established processes for obtaining timely and appropriate professional mental health advice when managing incidents involving individuals in crisis. I would like to assure His Majesty’s Coroner that GMP is committed to this work and recognises the direct link between mental health training and the ability of officers to respond safely and proportionately to individuals experiencing distress. The full review and redevelopment of GMP’s mental health training provision is a significant piece of work that will require careful sequencing, stakeholder engagement and structured quality assurance. It is anticipated that this programme of work will take approximately nine months to complete, allowing sufficient time for co-design with partners, pilot delivery, and evaluation to ensure the resulting training meets the needs of both officers and the public. During this period, GMP will continue to deliver its existing mental health-related training products to ensure officers retain a baseline level of knowledge and capability. In addition, refresher materials and updated guidance will be issued to frontline officers through established internal communication channels as required, particularly where emerging themes, operational learning or partnership insight identify areas where immediate reinforcement or clarification would enhance understanding. Consideration will also be given to opportunities to strengthen service delivery and officer awareness through established organisational learning processes, including learning panels, debrief forums, and multi-agency partnership groups. These mechanisms will ensure that any immediate learning relevant to officers’ interactions with individuals in mental health crisis is captured, disseminated and acted upon as necessary, while the longer-term training review continues I trust this response addresses the concerns raised. Yours sincerely Chief Constable
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