Grant Lowry

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS  
REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS  
2013  

THIS RESPONSE IS BEING SENT TO:  

Clare Bailey, HM Senior Coroner for the coroner area of Teesside & Hartlepool  

in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ dated 
30 March 2026 following an inquest into the death of Grant Nicholas LOWRY that 
concluded on 26 March 2026.  

1.  

RESPONDENT  

In  line  with  our  duty  under  Regulation  29  of  the  Coroners  (Investigations) 
Regulations  2013,  the  Chief  Constable  of  Cleveland  Police  provides  this 
response within 56 days (plus any extension granted) of the date of the Report 
to Prevent Future Deaths.  

2.   DATE OF RESPONSE 21st MAY 2026 

CORONER’S MATTERS OF CONCERN & DETAILS OF ACTION TAKEN 

HM Coroner’s Regulation 28 Notice the Coroner identified the following matters 
of concern (brief summary): 

During the inquest into Grant Lowry’s death in June 2022, issues with 
communication and record keeping  relating to searches for Grant were 
identified. The issues impacted on the quality and effectiveness of the searches 
undertaken to locate Grant Lowry. These issues also impacted police tasking of 
further and full searches of heat sources identified by the National Police Air 
Service (NPAS) helicopter.  

3. 

The specific issues (in bold), and the force’s response, are set out below: 
1. The location of the first NPAS heat source was not recorded accurately.  
2. The outcome of the search into the first NPAS heat source was not 
recorded accurately by the Officers involved or the police call handler, 
whether in an Officer's day book, or on the STORM log, OEL or CAD. This 
prevented re-tasking of a search at that area.  
3. The details of the second NPAS heat source were not heeded, whether 
by the Officers at Summerhill Park, the call handler or listening 
Supervision. This meant the heat source was not searched or recorded.  
4. There was no liaison between Hartlepool and Stockton officers during 
the search at Summerhill Park on the evening of 01.06.22. This 
contributed to an unorganised and uncoordinated search.  
5. There was inaccurate recording of which fields around Summerhill Park 
had been searched, which was relied upon by Supervision and prevented 
later searches of those areas.  
6. The family were told that no heat sources had been identified by NPAS. 

  
  
  
 
 
 
 
 Actions taken to address these concerns are as follows: 
The feedback and organisational learning set out in the statement provided by 
Greater Manchester Police (GMP) has been shared with staff via the force’s 
Specialist Training Tactical Governance Group. This group is responsible for 
ensuring that specialist training is identified and delivered through the force’s 
mandatory or annual training schedule, and that appropriate training is  
delivered to support operational requirements. The learning from GMP’s 
feedback has also been provided to the force lead for the Search portfolio, and 
includes prioritisation of the requirement to record: 

•  clear and comprehensive rationale for operational decisions, and  
• 

the necessity of ensuring that any critical search areas which cannot be 
thoroughly examined are explicitly documented and flagged for follow-up 
during daylight hours. 

In November 2024, the force introduced a First Line Leadership Development 
Programme for all operational Sergeants and staff equivalents. This input 
consisted of a week-long course and included development on how to manage 
incidents as an ‘Operational Bronze’ commander, outlining their supervisory 
responsibilities in accordance with College of Policing Authorised Professional 
Practice (APP). Recording of decision-making and supporting rationale was 
included as part of this input. A large cohort of operational bronzes have now 
been trained. 

Future continuous professional development (CPD) sessions for front line 
supervisors will include learning identified from this incident. New Sergeants 
and Inspectors training will be delivered by the end of 2026. A wider review of 
the incident is scheduled to take place in June 2026 to identify any staff 
development needs. Direct one-to-one reflective learning will be done with 
those staff identified as requiring additional training or development as a result 
of this inquiry. 

Since the incident, the force has made changes to how it supervises, handles 
and prepares officers for missing persons investigations: 

• 

• 

In January 2023 the force amended its structure to a Basic Command 
Unit (BCU) model. The BCU model is led by a Chief Superintendent, and 
consolidates resources, personnel, and emergency response across 
multiple neighbourhoods or boroughs to manage demand, improve 
flexibility, and deliver consistent policing.  This change aligned the force 
to the same operating model as the Local Authorities, and established 
four Local Policing Areas (LPA) of Hartlepool, Stockton, Middlesbrough 
and Redcar & Cleveland each led by a District Commander 
(Superintendent). One of the main benefits of adopting this model was 
increasing the provision of a Response Inspector across all four districts, 
instead of one Inspector for South (Redcar and Middlesbrough), and one 
Inspector for North (Hartlepool and Stockton). This ensures each LPA 
has a Response Inspector available to manage the initial response to 
critical incidents (such as high-risk ‘Missing From Home’ incidents) in line 
with relevant frameworks, ensuring appropriate resource and partner-
agency deployment and effective risk management takes place operating 
in line with the role and responsibilities of a Response inspector | College 
of Policing. 
In 2024, enhancements were made to the force digital records 
management system (referred to as Niche), which now enables real-time 
monitoring of all live ‘Missing From Home’ cases via a dedicated 

 
 
 
 • 

dashboard. The dashboard is accessible to Duty Inspectors and Silver 
commanders (24/7). As a result of this change, operational actions are 
more effectively tracked and handovers have improved.  
In October 2024, the Force introduced a dedicated Missing Persons 
Investigation Team consisting of a Sergeant and 6 officers to review live 
and long-term missing from home reports during office hours 7 days a 
week. This supplements the work of Response Inspectors 24/7 in this 
area.  

•  Specific Missing Persons training was rolled out late in October/early 

November 2024. This training was delivered to all control room teams, 
including call handlers, dispatchers and operational supervisors 
(Sergeants and Inspectors). There has been improved staff development 
by introducing regular staff training and briefing sessions. These 
sessions are in addition to scheduled CPD training days. 
In March 2025 the Force Control Room undertook a review of the 
Missing Persons question set, assessing it against the Authorised 
Professional Practice for Missing Persons. 

• 

Additional supervision has also been increased with explicit scrutiny of high-
risk missing persons investigations by senior officers (Silver Commanders): 
• 

In  December  2024,  the  force  amended  its  Silver  Commander  rota  to 
provide  visible  and  supportive  leadership  beyond  office  hours  and  into  
periods of heightened demand. Under the revised arrangements, Silver 
Commanders  now  operate  on  a  shift-based  system,  with  the  late-shift 
Silver Commander serving from 1700 to 0300 hours and remaining on-call 
until  7  am. This  ensures  a  physical  supervisory  presence  during  busier 
evening periods, enabling Silver Commanders to assume tactical control 
of  incidents  in  support  of  response  supervisors  and  operational  teams, 
and,  where  appropriate,  to  liaise  with  LPA  Inspectors,  partner  agencies 
and other stakeholders to develop initial and dynamic working strategies.  
•  The role of the Silver Commander in ‘Missing From Home’ investigations 
is to oversee the Duty Inspector’s tactical plan. The Silver Commander 
will also manage resourcing requirements to meet their strategic 
objectives.  

•  Where appropriate, the Silver Commander will liaise with local policing 
Inspectors, partner agencies and other stakeholders to develop initial 
and dynamic working strategies to support investigations. Silver 
Commanders are usually of the rank of Superintendent, and they 
provide oversight of all High Risk ‘Missing From Home’ incidents in the 
force.  

•  Further oversight is provided by Pacesetter meetings which take place 
twice a day, one in the morning (chaired by Gold (Chief Superintendent 
or Chief Officer))  and one in the evening (chaired by the Silver 
Commander or Force Incident Manager from the Force Control Room) 
where missing persons are a standing agenda item.  

•  To further strengthen capability and ensure consistency of approach, 

later in 2026 the cadre of Silver Commanders will receive annual CPD 
designed to enhance their knowledge, operational effectiveness and 
decision-making proficiency. The learning identified from this incident will 
be included as part of this. 

7.  There were delays in requesting PolSA Mutual Aid from neighbouring 
police forces.  

 
 
 8. There were delays in requesting the involvement of Mountain Rescue 
(with their dogs) and the police dog unit. 

Actions taken to address this concern is as follows: 
The force has significantly improved the operating procedures and governance 
around its Specialist Capabilities areas, including police dogs, to ensure 
sufficient resilience is maintained. In addition, the geographical distribution of 
Licenced Search Officers (LSOs) has been reviewed as part of the Specialist 
Capabilities Strategic Threat and Risk Assessment (STRA). Consequently, 
minimum staffing levels will be increased and more evenly aligned across the 
force area. 

Promotion of the PolSA role was undertaken in 2022 and 2023 to raise 
awareness among operational frontline Inspectors and Sergeants. PolSAs often 
provide advice remotely particularly in the early stages of an incident. Although 
specialist resources can be co-ordinated and scaled as an incident develops, 
the organisation is not always in a position, particularly during the earliest 
stages of a response, to immediately deploy fully constituted specialist teams or 
specialist capabilities.  

The PolSA course undertaken by PolSAs highlights the resources that may be 
utilised during a search such as National Police Air Service (NPAS) and Mountain 
Rescue Teams  (MRT).   In  addition,  MRT  recently provided  input  into Licenced 
Search Officers’ professional development, with the aim of raising awareness of 
the benefits they can bring to searches. 

A rota lead for PolSAs has been introduced. The lead reports into monthly rota 
governance  chaired  by  a  Superintendent.  The  chair  reports  strategic  rota 
assurance into an Assistant Chief Constable at the Specialist Capabilities Board. 
Having this increased scrutiny over all rotas, including each rota area having a 
dedicated  lead  officer,  provides  the  force  with  confidence  that  the  rotas  are 
sufficiently resilient and can respond 24/7 when required. Since this governance 
has been introduced the PolSA rota has been managed more effectively, with no 
reported adverse occurrences linked to resilience. 

Whilst the force has ensured that it undertakes all National Police Air Service 
(NPAS) allocated flying hours and maintains appropriate level of use of NPAS 
search capabilities, it has furthered its aviation capability for searches.  

Whilst NPAS remains a viable tactical option for supporting missing person 
searches, the force has significantly enhanced its drone capability since 2023. 
Cleveland Police now has 58 accredited drone pilots and an operational fleet of 
15 drones, providing a resilient and flexible asset. This capability is available at 
all times and is routinely employed in support of High Risk ‘Missing From Home’ 
investigations. The drones are equipped with advanced tracking functions and 
high-grade night imaging technology, enabling effective searching across 
challenging environments and in conditions where visibility is otherwise limited. 
In addition to conventional deployment, the force has introduced a fleet of 
drones through the Drone as First Responder (DFR) programme. 

Cleveland Police is the first northern force to adopt this pioneering capability, 
and one of only five forces nationally who have this capability. This capability 
enables a drone to be launched remotely by trained operators, within a defined 
geographical area, allowing the drone to arrive at the scene of an incident within 
60 seconds of a report being received by the Force Control Room. This rapid 

 
 
 
 
 
 
  
 deployment provides early situational awareness, supports initial threat and risk 
assessment, and allows for the swift identification of search areas, hazards, or 
persons of interest before ground units arrive. The drone capability significantly 
enhances the effectiveness and efficiency of the early response phase, 
particularly in time critical missing person investigations. There are wider plans 
to extend this capability in future.  

Issues with officer equipment 

During the inquest it was identified that the officer who was guided by 
NPAS to the first heat source did not have a full set of operational PPE for 
a search at night time in a dense area. The batteries on his torch and work 
mobile phone were flat. 

This will be referred to the force’s Dress and Equipment Group and the Heath & 
Safety Group to review the matter and learning from the inquest. Both the Dress 
and Equipment Group and the Health and Safety Group will review officer 
equipment requirements and personal protective equipment. Both Groups will 
consider whether the current provision and equipment requirements meet the 
requirements of conducting searches. In addition, direct one-to-one reflective 
learning will be included regarding individual officers’ responsibilities in respect 
of operational equipment and escalating issues with equipment to their 
supervisor. 

4.  

Cleveland Police continue to extend our deepest sympathy to Grant’s 
family and friends and apologise for the failings identified. 

5.   DETAILS OF FURTHER ACTION PROPOSED  

As per section 3, The following are actions which still require 
implementing by the force: 

Future Continuous Professional Development 
Future CPD sessions for front line supervisors will include learning identified 
from this incident. New Sergeants and Inspectors training will be delivered by 
the end of 2026. A wider review of the incident is scheduled to take place in 
June 2026 to identify any staff development needs. Direct one-to-one reflective 
learning will be done with those staff identified as requiring additional training 
or development as a result of this inquiry. 

To further strengthen capability and ensure consistency of approach, later in 
2026 the cadre of Silver Commanders will receive annual CPD designed to 
enhance their knowledge, operational effectiveness and decision-making 
proficiency. The learning identified from this incident will be included as part of 
this. 

Officer Equipment  
This will be referred to the force’s Dress and Equipment Group and the Heath 
& Safety Group to review the matter and learning from the inquest. Both the 
Dress and Equipment Group and the Health and Safety Group will review 
officer equipment requirements and personal protective equipment. Both 

 
 
 
 
  
 
 
 
 Groups will consider whether the current provision and equipment 
requirements meet the requirements of conducting searches. In addition, direct 
one-to-one reflective learning will be included regarding individual officers’ 
responsibilities in respect of operational equipment and escalating issues with 
equipment to their supervisor. 

6.  

SIGNATURE  

Chief Constable 
Cleveland Police

Community Modern Matron 
Stockton & Hartlepool AMH Planned Care 
Marton Road, Middlesborough 
Cleaveland 
TS4 3AF 

10th April 2026 

HM Senior Coroner 
Teesside Coroner’s Service 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

Dear Madam 

I write following conclusion of the Inquest touching the death of Grant Lowry. Following 
the Inquest, you asked the Trust to confirm "that staff are reminded to undertake a risk 
assessment when undertaking medication reviews". 

To  provide  further  assurance  regarding  risk  assessment  processes  following  clinical 
reviews, it is important to note that risk assessment is a continuous process in which 
clinicians are required to assess an individual's risks and any changes thereto on an 
ongoing basis. Should any changes in risk be identified during a review, these must be 
clearly  documented  within  the  electronic  care  records  and  within  the  patient's  risk 
assessment. 

During patient consultations, it is expected that risks are reviewed in accordance with 
the individual's presentation, mood, and sleep patterns, and that  direct questions are 
posed in relation to self-harm and suicidal ideation. In addition to risks to self, whether 
intentional or unintentional, clinicians are required to review risks from others, risks to 
others,  forensic  risks,  risks  arising  from  the  service  itself  (including  iatrogenic  harm), 
safeguarding concerns, and risks relating to physical health, among any other relevant 
risk factors. 

 
 
                                                                                                             
 
 
  
 
 In Grant's case a call was made to Grant's mother by a trainee nursing associate, has 
previously agreed, to discuss Grant's medication. Where contact is made with carers, 
their views are sought in accordance with the domains set out within the safety summary 
(risk assessment). In circumstances where information is being obtained from carers, it 
is  expected  that  a  general  discussion  is  undertaken  regarding  any  changes  in 
presentation that may have an impact upon the individual's risks. 

Following  the  Inquest  this  matter  has  been  escalated  through  the  Quality  Standards 
Group, which is chaired by the Associate Directors of Nursing and attended by Team 
Managers, Matrons, and Clinical Specialists. A formal discussion was held at the Quality 
Standards meeting on 8th April 2026 to address this information, with a request that the 
findings be cascaded to clinical teams accordingly. 

I can confirm that, following GL's death, changes have been made to the electronic care 
recording system currently in place. The system now incorporates an automatic prompt 
requiring  clinicians  to  confirm  whether  a  risk  assessment  has  been  reviewed  when 
completing a clinical entry; where it has not, a documented rationale must be provided. 

The electronic system is configured such that a clinician is unable to save a clinical entry 
without either confirming that an individual's risks have been reviewed or providing an 
explanation  as  to  why  this  was  not  possible.  Where  risks  have  not  been  reviewed 
directly with the patient, for example in circumstances where contact was made solely 
with a carer, this would be recorded as the rationale upon saving the clinical entry. 

I hope you are assured that learning arising from the Inquest has been acted upon and 
discuss with clinical teams. We reiterate our sincere condolences to Grant's family. 

Yours sincerely, 

Community Modern Matron