Investigation into a complaint about contact with a woman prior to her death - Greater Manchester Police, November 2022
In November 2022, officers from Greater Manchester Police (GMP) attended the home of a woman following a report she had taken an overdose. An ambulance had also been requested, both by the caller and by GMP.
The woman spoke with officers and said she would not go to hospital with them. She later agreed to go to hospital, but her condition deteriorated. Officers at the scene were told not to transport the woman to hospital until they had an update on the arrival of the ambulance.
An ambulance arrived almost two hours after being first informed of the incident. The woman went into cardiac arrest in the ambulance. She was taken to hospital where she was pronounced dead approximately an hour later.
During the investigation, investigators interviewed the three officers who attended the address, obtained statements from several witnesses, reviewed body-worn video footage and radio transmissions, and considered local and national policies.
The investigation concluded there was no indication any police officer may have behaved in a manner that would justify the bringing of disciplinary proceedings or committed a criminal offence.
We identified organisational learning relating to cross-agency working.
IOPC reference
Recommendations
The IOPC recommends that the North West Ambulance Service (NWAS), Greater Manchester Police (GMP), Cumbria Constabulary, Cheshire Constabulary, Merseyside Police, and Lancashire Constabulary finalise, agree, and implement the Joint Operating Protocol (JOP) as soon as practicable. Each agency should take action to ensure that all operational and control room staff are aware of the purpose and aims of the JOP, how it applies to that agency, and how it should be used by staff.
This follows an independent IOPC investigation concerning GMP’s response to a report that a female had taken an overdose [redacted] in November 2022. Officers attended on an emergency response and GMP control room staff requested the assistance of NWAS, however, there were delays in ambulance attendance.
During the IOPC investigation, the IOPC learned of a JOP that was in consultation at the time of this incident between the North West police forces and NWAS, and as of July 2023, it remains in consultation. The protocol creates a mechanism for police to escalate delays with ambulance attending the scene directly with senior managers in NWAS’ control room, delays such as the one in this case, however, the protocol is not yet agreed between the agencies and has been delayed since July 2022.
The IOPC is aware of the national rollout of the ‘Right Care, Right Person’ initiative. Right Care, Right Person is a programme of work that involves police and health partners working together to ensure that the correct agency is responding to calls such as concerns for welfare, mental health incidents or missing persons. This is to make sure that people in distress are receiving the most appropriate service but also to reduce demand on policing so that police can concentrate on their core duties and functions. Given the likely timescales for implementation of this initiative, it may be necessary to agree, and implement, an interim protocol until forces and the NWAS are in a position to fully implement ‘Right Care, Right Person’ (should they wish to do so).
Recommendation accepted:
Implementing the JOP
The North West Ambulance Service (‘NWAS’) is the lead agency for the development of the Joint Operating Procedure (‘JOP’).
Since Greater Manchester Police (‘GMP’) commenced Project Aurora – a project to implement the principles of Right Care, Right Person (‘RCRP’) into its operating model – the lead branch for progression of the JOP has been the Force Prevention Branch which took ownership of the JOP in mid-2023. Prior to this change of ownership, the JOP was owned by the Force Contact, Crime and Operations Branch (‘FCCO’). The reason for this change of ownership was to ensure the JOP aligned with the RCRP proposals being progressed within GMP and to make sure service delivery by GMP and NWAS would not negatively impact the communities of Greater Manchester by having two potentially contradictory processes in place.
NWAS currently chairs bi-weekly meetings in relation to the JOP, which are attended by all North West police forces and representatives from the relevant fire and rescue services and North West Fire Control (‘NWFC’). GMP is represented at these meetings by personnel from both the Force Prevention Branch and the FCCO (as the main business area affected by the JOP), to ensure the details contained within the JOP are accurate and reflective of correct working practices.
Further progress has been made to finalise, agree and implement the JOP since the inquest touching upon the death of [redacted] concluded. Version 1.0 of the JOP went live on 12 October 2023 with four of the five North West police forces, namely Cheshire Constabulary, Cumbria Constabulary, Lancashire Constabulary and Merseyside Police.
Other partner organisations, including GMP, have yet to agree to the JOP. GMP considers the wording contained within the section on ‘Identifying the Lead Agency’ creates ambiguity and could cause confusion. The current wording is not clear as to which organisation would be the lead agency in certain circumstances, particularly in instances when there may be scene safety concerns, and what such a designation would mean in practical terms. This section of the JOP also suggests that two organisations could be considered the lead agency at the same incident for different purposes (“the lead for the policing purpose would be the Police, NWAS would remain the Lead Agency for the health matter”). It is felt this current wording may create confusion between organisations, such as with regards to who is expected to deploy resources in the first instance which, in turn, may result in delays in deploying the right resources to the scene, thus putting service users at risk. The wording as currently drafted is also at odds with GMP’s RCRP proposals, specifically in relation to when GMP will deploy resources to medical incidents and when GMP would be acting as a lead agency or in support of NWAS.
GMP recognises the importance of the JOP and is committed to working with NWAS and the other North West police forces to produce a JOP that is fit for purpose and provides a high level of service from the most appropriate agency to people in need. To this end, GMP is continuing to work closely with all relevant partners, including NWAS, in order to reach a mutually agreeable solution which not only works within the current working environment but aligns with the future operating model of RCRP in Greater Manchester and across the North West region.
GMP and the four North West police forces which have signed up to the JOP are liaising with one another via the bi-weekly JOP meetings at the North West regional RCRP meetings and via separate conversations between each force to understand our respective positions with regards to the current version of the JOP. It is hoped that a mutually agreeable solution can be reached that would see GMP sign up to the JOP by the end of February 2024.
It is envisioned that once the ‘Identifying the Lead Agency’ section is amended, it will align to the current and proposed RCRP working practices for all contributing police services, meaning the JOP would not need further updates to align with the RCRP processes of each police service, nor would the content of the JOP be superseded by RCRP policies.
GMP is currently working closely with NWAS in respect of the RCRP project. Work is ongoing in relation to the response to be provided by police and ambulance resources to incidents of a physical health concern. To ensure an appropriate response is provided by both blue light services, a partnership agreement specific to Greater Manchester is currently in development. This partnership agreement will formally outline each organisation’s roles and expectations at incidents of Concern for Welfare (CFW) where the primary or sole nature of the incident relates to a physical health concern, and will ensure that GMP’s response to matters of physical health concern, in conjunction with NWAS, is aligned to the principles of RCRP and the regional JOP and that organisations meet their legal obligations under ECHR legislation.
It is envisioned that the Greater Manchester-specific partnership agreement and the regional JOP will work in cohesion and ensure processes specific to Greater Manchester are clearly understood by both organisations.
It is anticipated that this partnership agreement will be complete by the end of April 2024.
Communicating and explaining the JOP
Once the JOP has been agreed for launch in Greater Manchester, and before the implementation stage, there will be a process within the FCCO to ensure that all staff are made aware of the document and that they understand its purpose and aims, its relevance to GMP, and how it should be used by them. This message will be distributed by the senior leadership team within the FCCO to all supervisors within the branch for further cascading to all staff members.
In the interim, as the JOP has now been launched with all North West police forces except for GMP, to ensure there is no misunderstanding or incorrect application of the JOP within Greater Manchester, contact has been made with NWAS to ensure there is a mutual understanding that the JOP is not currently in place within Greater Manchester.
An interim protocol
In November 2022, communication was distributed throughout the FCCO outlining the escalation process between GMP and NWAS. This message was reinforced in June 2023 via internal messaging and is recirculated, as necessary, to ensure consistent compliance. What was initially introduced as an interim measure in 2022 is now considered “business as usual” and, through regular liaison with NWAS, is regarded as appropriate practice for both organisations. These escalation processes are outlined below:
- For GMP to obtain further information or an estimated time of arrival (‘ETA’) for an ambulance, a call to NWAS should follow normal process by a police dispatcher using the non-urgent ICCS hotkey (a system that is used to report an incident/pass information to partner agencies).
- The Hear and Treat service is an option for the officer on scene to discuss the circumstances with a clinician. An ambulance may not always be required, and advice can be passed. It is highlighted to officers that this service is not to be used to try and upgrade the ambulance response or to give information that the patient’s condition has deteriorated or worsened in any way. In such circumstances, NWAS must be called on 999 or ICCS for the incident to be triaged again.
- Should GMP experience any issues, such as significant delays in ambulance attendance when police are already on scene, and contacting NWAS using the non-urgent number has failed to resolve the issue, GMP can contact the NWAS Emergency Operations Centre (‘EOC’) performance manager via agreed telephone lines which have been distributed within the FCCO. This number is only to be used by supervisors/duty managers and is not to be used to report a change in the patient’s condition.
- If there is a requirement for further escalation, the GMP duty manager/inspector only can contact the NWAS GM EOC duty manager via an agreed telephone number. This number is not to be made available to anyone outside of the FCC and is only available to inspectors or above to ensure the integrity of the service.
- Any further escalations will be via the Force Duty Officer (‘FDO’) as per current processes.
- GMP now also has access to the NWAS cancellation line in order to cancel an ambulance. This bypasses the NWAS call handlers and is a direct number to their dispatch room. It may also be used to discuss any particular concerns where officers have remained on scene, but escalation is not yet required. This number is available for use by GMP dispatchers but must not be used to give updates to NWAS about the patient’s condition.
- GMP is also working on a process for NWAS to escalate to GMP via the dispatch duty inspector prior to making contact with the FDO, as a resolution can often be found without FDO intervention.
- The Hear and Treat service has been relaunched across GMP. This was communicated to officers and staff forcewide on 4 October 2023 via the Force intranet. An article has been published on the intranet which outlines the purpose and benefits of the Hear and Treat service alongside the contact telephone number for use by frontline officers.
- The Force Operations Centre collates daily data regarding any delays between the two services and reports to FCCO senior leadership every Monday.
- Weekly meetings between senior GMP, NWAS and Greater Manchester Fire and Rescue Service (‘GMFRS’) colleagues are held to discuss demand and any issues that have occurred during that week.
Whilst work with partners to implement a mutually agreeable JOP in Greater Manchester continues, the above measures are in place to ensure GMP and NWAS can communicate and escalate concerns via agreed processes where necessary.
Lancs Police - received 4th Oct 2023 - accepted
Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This has now been agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs will go live on Thursday 12th October 2023. It has also been agreed with the regional Forces and NWAS that fortnightly meetings will continue until North-West Fire are in a position to proceed with the agreement.
Lancashire Police are already working closely with North-West Regional Forces and North-West Ambulance Service in relation to agreed processes in the Joint Operating Protocol. The document will provide clarity and guidance to Control Room staff. Implementation will be via email/briefing to all Force Control Room Supervisors and Force Incident Managers.
Operational and Control Room staff will be made aware of the purpose and aims of the JOP, how it applies to that agency, and how it should be used by staff; Once the document is live this will be cascaded to operational staff via Divisional Response Inspectors and Response Sergeants during their briefings. Control Room staff will be briefed via their supervisors, and this will be embedded into future Control Room training days.
Cumbria Police - received 1st Feb 2024 - accepted
Cumbria adopted the regional standard operating procedure in October 2023. We are currently in our implementation phase of RCRP, with an expected go live of 14th May 2024.
Cheshire Police - received 6th Oct 2023 - accepted
Cheshire Constabulary have been fully engaged and have signed up to implement the new Joint Operating Protocol between Regional Forces, Fire Services (CFRS) and NorthWest Ambulance Service (NWAS) following the enquiry into the death of Claire Briggs.
Cheshire Constabulary regularly work closely with colleagues from Cheshire Fire and Rescue and NWAS.
Following a PSD review several years ago, the FCC Leadership team worked closely with colleagues from NWAS, to implement an escalation process to be able to discuss and review deployment grading decisions by NWAS. This protocol allowed Force Incident Sergeants and Force Incident Managers to ring the Deployment Manager in the NWAS control room to request urgent reviews where, in the police’s view, there was mitigation to request a review of a grading given the circumstances presented to officers. This has been in place for over 7 years.
In addition to this, the force worked closely with colleagues from NWAS to prevent any degradation of service because of excessive demands on NWAS and more recently the joint control room working throughout the industrial action.
In 2016, to further evidence the excellent joint working with CFRS and NWAS, Cheshire Constabulary instigated a Forced Entry Protocol which sees CFRS (when notified by NWAS) to attend reports of concern for welfare for members of the public where a forced entry is/was required. Following a short 8-month trial this accepted by all parties as business as usual and this now accounts for 8% of CFRS daily business. Whilst it is accepted as daily business, good relationships remain embedded and discussions around this process take place to discuss its ongoing management and success.
More recently, following the recommendations of Op Mantalene (MEN Bombings), the force regularly engages in regional testing (with CFRS, NWAS and all Regional Forces) and the management of the new Emergency Services Interoperability Control channel (ESICTRL). This is tested daily, with Cheshire taking its part in month long ownership for that testing every June.
Merseyside Police - received 2nd February 2024 - accepted
MS Police accept the recommendation. Chief Supt. [redacted] (Head of Merseyside Police Response and Resolution ) agreed the JOP with NWAS on behalf of Merseyside Police on the 3rd October 2023.
In regard to the RCRP, Merseyside Police ‘go live’ as follows –
- Phase 1 (concern for welfare and walk out from hospital) on 29th April 2024
- Phase 2 (AWOL from MH establishments) in Sept 2024
- and Phase 3 (S136 observational role) in March 2025
NWAS - received 3rd Nov 2023 - accepted
Further to our communication on 28 July 2023, which was our initial response to the consultation around the issuing of the Paragraph 28 recommendation, we can provide the following update to the process and subsequent actions around the implementation of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs’ (JOP).
Following the coronial inquest into the death of [redacted] on 10 – 13 July 2023 (and as confirmed in evidence provided by the Trust during the inquest), the JOP implementation process was restarted with all Police Partners. This involved fortnightly meetings with all parties to agree a standard format and wording for the JOP to be used across the whole NWAS footprint.
Following these meetings, we can confirm that as of 12 October 2023 the JOP version one went live within NWAS in conjunction with Cheshire, Cumbria, Lancashire and Merseyside Police Forces. As of yet this has not been adopted by Greater Manchester Police, with discussions still ongoing, Nevertheless, it was considered important that the process and implementation was not delayed.
Great Manchester Police Force have a couple of points that it wishes to be addressed prior to adoption of the JOP. Its central point concerns the term ‘Lead Agency’. We requested an alternate, suggested form of words for the rest of the group to agree on 26 October 2023 and await a response. As previously stated, we are working closely with Greater Manchester Police to overcome any remaining barriers to its implementation of the JOP.
Future work will include British Transport Police, North West Fire Control, Fire and Rescue Services from Lancashire, Greater Manchester, Cheshire and Cumbria. This will be beneficial as the whole of the North West will be working within the same process.
There is an expectation that the JOP will move to version 2 as other agencies are onboarded, and as the implementation of right care right person by the Police Forces and any subsequent lessons are identified.
We hope that this provides reassurance that we as an organisation continue to take positive actions following the sad death of Ms [redacted], the subsequent outcome of the coronial process and the findings of the IOPC investigation.