Recurring concern

Unreliable police incident dispatch and response under service demand

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First reported 6 Oct 2014•Latest report 8 May 2026

Definition

What this concern includes

Includes dispatch visibility, allocation, officer capacity and attendance failures that prevent priority police incidents receiving a timely response.

Not included

Investigation quality after attendance
Emergency medical or ambulance dispatch
Non-priority administrative police work

Reports: 8
Individual concerns: 14
Date range: 2014–2026
Stated actions: 36

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Greater Manchester Police2

Home Office2

West Midlands Police2

British Transport Police1

Derbyshire Constabulary1

Environment Agency1

National Police Chiefs’ Council1

Northumbria Police1

Police and Crime Commissioner for West Midlands1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

8 May2026
Surrey
Concerns raised3
1. Lack of safeguards preventing erroneous removal of priority logs from the dispatch queue
2. Failure to deploy a unit or add a significant update before removing a priority incident from the dispatch queue
3. Failure to ensure senior-officer endorsement and supervisory oversight of immediate and priority grade logs
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Require supervisory review and endorsement of control-room logs before progression, deprioritisation or release from active management.
  Stated by British Transport PoliceStated completed
2. Action
  Explore with the information-system provider a software safeguard or prompt adding prevention or supervisory control before logs leave sub-queues.
  Stated by British Transport PoliceStated in progress
Respondent positions 1
1. Position
  Logs cannot be prevented from moving between queues because such movement is operationally necessary; strengthened supervision is used instead.
  Stated by British Transport PoliceDisputes the concern
AI-generated summary

SHAY MIDDLETON-PIERCE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shay Middleton-Pierce, aged 15, died on 29 March 2025 from multiple traumatic injuries following suicide near the Nutfield train line crossing in Redhill, Surrey. British Transport Police failed to establish whether officers could meet him at Redhill Station and did not inform Surrey Police that they were not attending after the incident log was moved from the dispatch queue to a sub queue in error. The report raises concerns about human error, insufficient supervisory oversight, and the lack of computer checks to prevent priority logs being removed from dispatch attention.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of safeguards preventing erroneous removal of priority logs from the dispatch queue
Wider context from the report
“The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers. The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place. Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this. None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident. The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher. A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff. ”
Source location
SHAY MIDDLETON-PIERCE · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to deploy a unit or add a significant update before removing a priority incident from the dispatch queue
Wider context from the report
“The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers. The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place. Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this. None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident. The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher. A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff. ”
Source location
SHAY MIDDLETON-PIERCE · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure senior-officer endorsement and supervisory oversight of immediate and priority grade logs
Wider context from the report
“The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers. The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place. Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this. None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident. The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher. A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff. ”
Source location
SHAY MIDDLETON-PIERCE · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require supervisory review and endorsement of control-room logs before progression, deprioritisation or release from active management.

Verbatim wording from the response
“Recognising that supervision by the FIM/DFIM and Team Managers is a critical safeguard, BTP has implemented a comprehensive set of procedural and supervisory controls:”

Source location
Response from British Transport Police
Page 2 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Explore with the information-system provider a software safeguard or prompt adding prevention or supervisory control before logs leave sub-queues.

Verbatim wording from the response
“Technology Opportunities”

Source location
Response from British Transport Police
Page 5 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Logs cannot be prevented from moving between queues because such movement is operationally necessary; strengthened supervision is used instead.

Verbatim wording from the response
“As part of a cohesive approach, BTP is exploring with the provider of its FCR Information Technology system whether a technological software safeguard or prompt could be developed to either reduce the potential for this user error, or to add an additional supervisory control on the computer system before a log is released from a sub-queue dispatch control group. This will be examined to accompany the controls of the current command and control system, balanced against the overall significant daily service demand and other operational requirements.”

Source location
Response from British Transport Police
Page 5 · response
Published 10 July 2026
Open published response
4 Sep2025
Birmingham and Solihull
Concerns raised1
1. Insufficient resources for timely allocation of police officers to priority cases
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide increased police funding for 2025–26 settlements, pay awards, employer contributions and officer maintenance.
  Stated by Home OfficeStated in progress
2. Action
  Provide £200 million nationally to kickstart recruitment of 13,000 additional neighbourhood-policing officers, PCSOs and special constables.
  Stated by Home OfficeStated in progress
3. Action
  Set expectations for forces to reduce inefficiencies and maximise productivity through the Police Efficiency and Collaboration Programme.
  Stated by Home OfficeStated completed
Respondent positions 1
1. Position
  Local Police and Crime Commissioners, Mayors and Chief Constables are responsible for resourcing decisions according to local needs.
  Stated by Home OfficeRedirects responsibility
AI-generated summary

Khalif Mohammed · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Khalif Mohammed, who was detained in hospital under section 3 of the Mental Health Act, failed to return from unescorted leave on 6 January 2025 and was found deceased at his flat the following day. The medical cause of death was recorded as haemopericardium and haemothorax due to a stab wound, and the inquest conclusion was suicide. The report raised concerns about insufficient police resources and a significant delay in allocating officers to his priority missing-person case.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient resources for timely allocation of police officers to priority cases
Wider context from the report
“1. The inquest heard that West Midlands Police had insufficient resources to allocate police officers to deal with Khalif's case on 06/01/25 which was classed as a priority case with expected allocation of resources within an hour. As a result, there was a significant delay in officers being allocated to the case. Whilst it could not be shown that this affected the outcome for Khalif, there is a risk of future deaths if the available resources are not sufficient to deal with the large numbers of cases received each day and in my view, action should be taken. ”
Source location
Khalif Mohammed · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide increased police funding for 2025–26 settlements, pay awards, employer contributions and officer maintenance.

Verbatim wording from the response
“The Chancellor has announced a real terms increase in police spending power over the next three years. For this financial year, the 2025-26 final police funding settlement provides funding of up to £19.6 billion for the policing system in England and Wales. This is an overall increase of up to £1.2 billion when compared to the 2024-25 settlement. West Midlands Police will receive up to £846.9 million in funding in 2025-26, an increase of up to £56.5 million (7.2%) when compared to the 2024-25 police settlement.”

Source location
Response from Home Office
Page 1 · response
Published 16 September 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide £200 million nationally to kickstart recruitment of 13,000 additional neighbourhood-policing officers, PCSOs and special constables.

Verbatim wording from the response
“In addition to the funding announced at the settlement, we are providing £120 million of in-year funding to support forces in meeting the cost of the 2025-26 pay award. The settlement also includes funding to support the costs of the 2024-25 pay award, the increase in the employer national insurance contributions, funding for officer maintenance and an additional £200 million nationally to kickstart the first phase of recruiting 13,000 additional police officers, PCSOs and special constables into neighbourhood policing roles.”

Source location
Response from Home Office
Page 1 · response
Published 16 September 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Set expectations for forces to reduce inefficiencies and maximise productivity through the Police Efficiency and Collaboration Programme.

Verbatim wording from the response
“It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that”

Source location
Response from Home Office
Page 1 · response
Published 16 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Local Police and Crime Commissioners, Mayors and Chief Constables are responsible for resourcing decisions according to local needs.

Verbatim wording from the response
“It is the responsibility of locally elected Police and Crime Commissioners, Mayors and Chief Constables to take decisions around their resourcing according to local needs. However, the Government recognises the challenges faced by police chiefs in prioritising finite resources and is committed to ensure that police forces can effectively tackle a wide range of public safety issues. We have set out our expectation to forces to reduce inefficiencies and maximise productivity driven through a new Police Efficiency and Collaboration Programme. This will free up cashable savings and officer time to reinvest in frontline activities. The Government will continue to engage with forces to ensure that”

Source location
Response from Home Office
Page 1 · response
Published 16 September 2025
Open published response
15 Apr2024
Gateshead and South Tyneside
Concerns raised2
1. Failure to grade vulnerable incidents at the appropriate level
2. Insufficient police resources causing delays in attendance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Embed THRIVE assessment and related best-practice learning as a standing item in Communications staff Protected Learning Days.
  Stated by Northumbria PoliceStated completed
2. Action
  Implement an enhanced process for delayed Grade 2 incidents, including escalation, caller re-contact, renewed risk assessment and safeguarding consideration.
  Stated by Northumbria PoliceStated completed
3. Action
  Establish a full-time Risk Management Desk to reassess risks and grading for vulnerable Grade 2 incidents delayed beyond one hour.
  Stated by Northumbria PoliceStated completed
1. Action
  Introduce a Grade 3 response with dedicated resources, 24-hour deployment, victim-availability scheduling and single-crewed officers.
  Stated by Northumbria PoliceStated planned
2. Action
  Provide each Response Team with a dedicated Sergeant to review incidents and assist Communications staff with resource allocation.
  Stated by Northumbria PoliceStated completed
3. Action
  Implement the new Operating Model, including staff realignment, enhanced area leadership and increased response-policing officer numbers.
  Stated by Northumbria PoliceStated completed
AI-generated summary

Stevyn Carr · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stevyn Carr was found dead at his home on 16 November 2021 after contacting Northumbria Police the previous evening and requesting help. Police did not attend until more than 16 hours after his first contact, following a further call from his family. The principal concerns were the grading and delayed handling of the incident, lack of oversight and alternatives when resources were unavailable, and uncertainty about whether Northumbria Police’s subsequent changes had improved the timeliness of responses.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to grade vulnerable incidents at the appropriate level
Wider context from the report
“(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response. (2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued. (3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him. (4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time. (5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving. ”
Source location
Stevyn Carr · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient police resources causing delays in attendance
Wider context from the report
“(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response. (2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued. (3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him. (4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time. (5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving. ”
Source location
Stevyn Carr · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Embed THRIVE assessment and related best-practice learning as a standing item in Communications staff Protected Learning Days.

Verbatim wording from the response
“There have been improvements across the department in terms of the identification of vulnerable victims and incidents which have centred around the THRIVE assessment made by the contact handler, which looks to identify threat, harm risk, investigative opportunities, vulnerability and level of engagement at the first point of contact, but also through the life of the incident with further THRIVE assessments completed when required. THRIVE has become a standing agenda item on the Protected Learning Days for Communications staff which includes best practice alongside areas of learning.”

Source location
Response from Northumbria Police
Page 2 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement an enhanced process for delayed Grade 2 incidents, including escalation, caller re-contact, renewed risk assessment and safeguarding consideration.

Verbatim wording from the response
“In relation to the actual incident, it is believed this would now be identified as a vulnerable incident but a definitive response to this cannot be provided as each assessment is a subjective assessment made by an individual. We have however implemented an enhanced process for Grade 2 incidents that were not attended within SLA to ensure a continued assessment of the risk.”

Source location
Response from Northumbria Police
Page 2 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a full-time Risk Management Desk to reassess risks and grading for vulnerable Grade 2 incidents delayed beyond one hour.

Verbatim wording from the response
“There is now a full time Risk Management Desk in place, whose responsibility is the ongoing assessment and mitigation of risk within vulnerable incidents. If a caller is classified as Vulnerable from their initial Grade 2 (G2V) call then in the event the incident is not responded to within one hour the Risk Management Desk will re-contact the caller and undertake a full review of their risks and vulnerabilities and assess if the incident requires a change of grading.”

Source location
Response from Northumbria Police
Page 2 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a Grade 3 response with dedicated resources, 24-hour deployment, victim-availability scheduling and single-crewed officers.

Verbatim wording from the response
“Recognising that our performance for non-emergency incidents could be improved, a review of the deployment model has been completed. This review has led to the introduction of a Grade 3 response which will have dedicated resources to deploy to the incidents within 24 hours of the caller contacting the police. The response will be diarised in accordance with victim availability and will be serviced by single crewed officers. Incidents which will remain graded as G2 incidents will be those with elements of vulnerability or other time critical issues. This change to the grading structure enables Communications staff and frontline officers to identify which non-emergency incidents require a timelier response, to enable them to deploy resources more appropriately.”

Source location
Response from Northumbria Police
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide each Response Team with a dedicated Sergeant to review incidents and assist Communications staff with resource allocation.

Verbatim wording from the response
“In addition, since the incident each Response Team now has a dedicated Sergeant who reviews incidents and assists the Communications Department in assigning resources. This ensures a swifter level of service.”

Source location
Response from Northumbria Police
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the new Operating Model, including staff realignment, enhanced area leadership and increased response-policing officer numbers.

Verbatim wording from the response
“The Force moved to a new Operating Model on the 4th March this year which included a re-alignment of staff to each of the 6 area commands and a more enhanced leadership structure for each area. This means that there are increased officer numbers working in response policing giving us a better ability to meet calls for service in a timely manner aligned to more focussed leadership and accountability. Although the model has only been running for a short period of time it is evident this has had a positive impact with improvements in the percentage of incidents attended within our stated times, a 13.3% improvement in grade 2 incidents and”

Source location
Response from Northumbria Police
Page 3 · response
Published 29 April 2024
Open published response
21 Dec2022
Manchester West
Concerns raised1
1. Failure of police officers to attend incidents within policy timescales
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the Incident Response Policy to address incident attendance and agency responsibility concerns.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Implement the current Incident Response Policy incorporating THRIVE risk assessment for incident grading and response decisions.
  Stated by Greater Manchester PoliceStated completed
3. Action
  Provide and maintain IRP and THRIVE training for FCC officers and staff through initial instruction, audits, briefings, and new-joiner programmes.
  Stated by Greater Manchester PoliceStated completed
AI-generated summary

Angeline Marie Phillips · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Angeline Marie Phillips died at her home on 30 January 2021 after police and ambulance services were contacted following concerns about her welfare and previous suicide attempts. The principal concern was that police did not attend within the required response time and responsibility was passed to a third party, with concerns that the policy could allow similar delays and risks to future deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of police officers to attend incidents within policy timescales
Wider context from the report
“1) During the Inquest evidence was heard that: - a) The Greater Manchester Police Incident Response Policy governed the grading of an Incident in relation to priority and the response time to an Incident. b) In relation to the grading of the Incident relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident with the Incident having been referred to NWAS without a police officer attending. c) The Greater Manchester Police Incident Response Policy makes no reference of an option to refer the Incident to a 3rd Party, such as NWAS, but there is no specific reference in the Policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or any other agency. d) I am concerned that unless the Greater Manchester Police Incident Response Policy is reviewed police officers will not attend Incidents within the timescales referred to in the Policy and there will be an opportunity to pass the responsibility to 3rd party agencies, which may lead to a risk that future deaths could occur unless action is taken. ”
Source location
Angeline Marie Phillips · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Incident Response Policy to address incident attendance and agency responsibility concerns.

Verbatim wording from the response
““A review of the Greater Manchester Police Incident Response Policy to consider specific reference in the policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or another agency””

Source location
Response from Greater Manchester Police
Page 1 · response
Published 4 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the current Incident Response Policy incorporating THRIVE risk assessment for incident grading and response decisions.

Verbatim wording from the response
“As a result, on 1st February 2022, GMP implemented the current IRP which incorporates the nationally recognised risk assessment approach to incident grading known as THRIVE (Threat, Harm, Risk, Investigation, Vulnerable and Engagement). The THRIVE process has been implemented since the tragic death of Ms Phillips and represents a significant change from the procedures that were in place at that time.”

Source location
Response from Greater Manchester Police
Page 1 · response
Published 4 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide and maintain IRP and THRIVE training for FCC officers and staff through initial instruction, audits, briefings, and new-joiner programmes.

Verbatim wording from the response
“Force-wide training on the IRP was provided to GMP officers and staff during its initial implementation, to ensure all of those who are required to follow the policy are clear about their responsibilities so that the appropriate grade is applied to each incident.”

Source location
Response from Greater Manchester Police
Page 1 · response
Published 4 January 2023
Open published response
27 May2021
Manchester North
Concerns raised1
1. Inadequate resourcing and allocation of officers to grade 2 calls within an hour
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Zeyna Partington · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate resourcing and allocation of officers to grade 2 calls within an hour
Wider context from the report
“2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all. ”
Source location
Zeyna Partington · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jan2020
Worcestershire
Concerns raised4
1. Failure to resource and attend P2 incidents within 60 minutes during increased demand
2. Failure to deal with P2 incident logs within the required time
3. Inaccurate and incomplete monitoring of open and overdue P2 incident logs
1. Insufficient police officers to resource and attend P2 incidents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Operate the revised dispatch model with a dedicated triage terminal, supervisory incident reviews, and 24-hour reassessment and transfer of unresolved incidents.
  Stated by West Midlands PoliceStated completed
2. Action
  Introduce a performance analysis tool providing incident and resource-demand data at 15-minute intervals.
  Stated by West Midlands PoliceStated planned
3. Action
  Use the closest available resource to support front-end incident-log demand.
  Stated by West Midlands PoliceStated completed
1. Action
  Transfer incident logs between control rooms to share demand across available staff.
  Stated by West Midlands PoliceStated completed
2. Action
  Implement the new Command and Control system, embedding THRIVE and improving incident, risk, and demand management.
  Stated by West Midlands PoliceStated completed
3. Action
  Involve the Force Incident Manager during particularly busy response shifts to redeploy resources from outside the area or to another policing area.
  Stated by West Midlands PoliceStated completed
4. Action
  Implement a Log Closure Doctrine to support dispatcher decision-making and focus resources on calls requiring greatest need.
  Stated by West Midlands PoliceStated completed
5. Action
  Improve contact handling by identifying lower-risk or non-policing incidents that do not require higher-priority control-room responses.
  Stated by West Midlands PoliceStated completed
6. Action
  Use Force Support Unit staff to manage legacy demand.
  Stated by West Midlands PoliceStated completed
7. Action
  Allocate logs unresolved at 96 hours to an appropriate Neighbourhood Policing Unit resource for ownership until finalisation.
  Stated by West Midlands PoliceStated completed
8. Action
  Transfer logs more than 24 hours old to a different team so dispatchers can focus on critical calls.
  Stated by West Midlands PoliceStated completed
9. Action
  Replace the incident snapshot presentation and establish an online dashboard to support understanding of available resources.
  Stated by West Midlands PoliceStated completed
Respondent positions 2
1. Position
  Existing systems and processes are considered sufficient to support control-room staff in managing competing demands, assessing risk and deploying resources.
  Stated by West Midlands PoliceExisting arrangements considered sufficient
1. Position
  Resource constraints limit the ability to respond to emergency calls within an appropriate time, despite prioritisation and efficient allocation of available resources.
  Stated by West Midlands PoliceUnable to act
AI-generated summary

Jason Paul DEVOTI · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jason Devoti had a history of mental health issues and alcohol dependency and was found deceased in accommodation on 9 October 2018 after West Midlands Police failed to attend a P2 welfare-check request for more than 22 hours. The inquest heard that he died from acute ethyl alcohol poisoning, although the time of death could not be established. The principal concerns were police control-room backlogs, inadequate escalation and training, and the risk that vulnerable people subject to P2 incidents would not receive a timely response during periods of increased demand.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to resource and attend P2 incidents within 60 minutes during increased demand
Wider context from the report
“(5) I am concerned at how overwhelmed those working in the Bournville control room had been by the increased demand on resources, and how their views about any improvement in the situation in the months following Jason's death did not appear to match what I was told by ████████ I was also concerned about the lack of awareness of and implementation of whatever escalation process may have been in place in the control room at the time of these events; this suggests a lack of appropriate training. Whilst I understand that the West Midlands force is undergoing a period of transition so far as their control rooms are concerned, I am not satisfied that measures to have yet been put in place to ensure that all those working in control rooms have received sufficient and appropriate training to deal with situations of increased demand. (6) I therefore remain concerned that in times of increased demand, and particularly unanticipated demand, there is a risk that West Midlands Police will be unable to resource and attend a P2 incident within the 60 minute period that is their stated aim, and that in turn will create a risk of death of the subject of such a P2 incident, if vulnerable and at some risk of harm as Jason Devoti undoubtedly was. ”
Source location
Jason Paul DEVOTI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to deal with P2 incident logs within the required time
Wider context from the report
“(2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that: (a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift; (b) That many of those logs would be "overdue" – which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at; (c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with; (d) That if there was an escalation process in force at the time, then: (i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or (ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done; (e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents, but also because there were not enough staff in the control room to work through the logs; (f) That measures taken to reduce the number of overdue logs ( known as ████████ ) would provide only temporary respite before the number of overdue logs built up again; (g) That at various times since these events, there had been little improvement in the situation: in January 2019 the situation was "still overwhelming" ( ████████ ); in June 2019 there would always be a lot of overdue logs ( ████████ ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( ████████ ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( ████████ ). ”
Source location
Jason Paul DEVOTI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inaccurate and incomplete monitoring of open and overdue P2 incident logs
Wider context from the report
“(4) In order to try to assist with understanding the figures involved, I was provided with a number of tables designed to give a "snapshot" of current logs and available police resources at particular times, viz. 8-9 October 2018, 8 October 2019 and 7 October 2020. In my view, this provided limited assistance as (a) the column giving the total of logs open appeared to be incorrect as it did not tally with the figures within other columns, and (b) it was not possible to see how many of the open logs were overdue, and in particular how many of the P2 logs had passed the critical one hour mark without a response. ”
Source location
Jason Paul DEVOTI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient police officers to resource and attend P2 incidents
Wider context from the report
“(2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that: (a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift; (b) That many of those logs would be "overdue" – which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at; (c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with; (d) That if there was an escalation process in force at the time, then: (i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or (ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done; (e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents, but also because there were not enough staff in the control room to work through the logs; (f) That measures taken to reduce the number of overdue logs ( known as ████████ ) would provide only temporary respite before the number of overdue logs built up again; (g) That at various times since these events, there had been little improvement in the situation: in January 2019 the situation was "still overwhelming" ( ████████ ); in June 2019 there would always be a lot of overdue logs ( ████████ ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( ████████ ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( ████████ ). ”
Source location
Jason Paul DEVOTI · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate the revised dispatch model with a dedicated triage terminal, supervisory incident reviews, and 24-hour reassessment and transfer of unresolved incidents.

Verbatim wording from the response
“b. Changes to control room model - The model that is used within dispatch is continually reviewed to ensure that it delivers the most effective approach. Changes were implemented in the summer of 2019 in order to manage incoming demand and the risk contained within existing logs. This includes the introduction of a dedicated triage terminal. This terminal does not hold legacy demand, therefore is able to review every new incident log sent to”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 3 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a performance analysis tool providing incident and resource-demand data at 15-minute intervals.

Verbatim wording from the response
“6. There is acceptance that there is still work more to do, including the introduction of a new Command and Control System and a performance analysis tool which provides incident and resource demand data at 15 minutes periods in order that this can be easily identified and responded to. This has continued to improve the position demonstrated by the snapshots presented as evidence and described at Point 4 above.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 4 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use the closest available resource to support front-end incident-log demand.

Verbatim wording from the response
“b. Use of the closest available resource to support with front end log demand.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 4 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Transfer incident logs between control rooms to share demand across available staff.

Verbatim wording from the response
“d. Load sharing across control rooms to match demand with resource. Logs are now transferred to another control room to ensure that demand is equally managed across all staff.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 5 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the new Command and Control system, embedding THRIVE and improving incident, risk, and demand management.

Verbatim wording from the response
“b. THRIVE is now embedded into the new Command and Control system and was delivered to all Force Contact staff as part of the training for the system ‘go live’.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 5 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Involve the Force Incident Manager during particularly busy response shifts to redeploy resources from outside the area or to another policing area.

Verbatim wording from the response
“16. Before and since the events leading up to Mr Devoti’s death, West Midlands Police has taken steps to ensure that the Response resources it has available are allocated as swiftly and efficiently as possible to all emergency calls. In addition to those measures set out above the following steps have also been taken:”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 6 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a Log Closure Doctrine to support dispatcher decision-making and focus resources on calls requiring greatest need.

Verbatim wording from the response
“b. Instituting a “Log Closure Doctrine” to encourage bolder decision-making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls requiring greatest need.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 6 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve contact handling by identifying lower-risk or non-policing incidents that do not require higher-priority control-room responses.

Verbatim wording from the response
“e. This has been combined with a focus within Contact handling, around the policing purpose for incidents. Historically there were incidents being created as a P2 that were lower risk and should have been graded as a P3, or where there was no policing response required. This has further reduced unnecessary demand on control rooms.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 4 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use Force Support Unit staff to manage legacy demand.

Verbatim wording from the response
“8. It was presented during the inquest that the reason for the number of outstanding incident logs was due to resourcing challenges because of austerity and the availability of officers to deploy. This has been addressed in a number of ways since the incident involving Mr DEVOTI:”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 4 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Allocate logs unresolved at 96 hours to an appropriate Neighbourhood Policing Unit resource for ownership until finalisation.

Verbatim wording from the response
“c. Support from Neighbourhood Policing Unit senior leaders to allocate logs unresolved at 96 hours to the most appropriate resource to own until finalised.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 5 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Transfer logs more than 24 hours old to a different team so dispatchers can focus on critical calls.

Verbatim wording from the response
“c. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by a different team so that dispatchers can concentrate on the most critical calls without the distraction of managing older logs.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 6 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Replace the incident snapshot presentation and establish an online dashboard to support understanding of available resources.

Verbatim wording from the response
“10. In relation to point 4 of HM Coroners’ areas of concern, it is accepted that there were some issues with how the ‘snapshot’ was completed. This has been addressed and as seen during the inquest, this snapshot has been changed to simplify what is being presented and an online dashboard is now in place to support the understanding of resources.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 5 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing systems and processes are considered sufficient to support control-room staff in managing competing demands, assessing risk and deploying resources.

Verbatim wording from the response
“13. In relation to the lack of resources to deal with incidents, the introduction of the escalation process allows for the use of any resource to respond to an incident where the risk dictates. It has taken time to embed this process and we are now seeing this supporting delivery. This has become more focused during Force TRM, held three times a day, where decisions are made to move additional resources according to demand.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 6 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Resource constraints limit the ability to respond to emergency calls within an appropriate time, despite prioritisation and efficient allocation of available resources.

Verbatim wording from the response
“14. It is right to reflect the positive news of an uplift to police resources over the next three years, recently announced by the Government and these are welcomed. It is necessary to acknowledge the impacts of austerity through the funding formula over the last five years particularly on West Midlands Police and the challenge this has created in managing increasing demand levels.”

Source location
2020-0017-Response-from-West-Midlands-Police_Redacted
Page 6 · response
Published 8 February 2020
Open published response
12 Aug2019
Birmingham and Solihull
Concerns raised1
1. Insufficient resources to deal with the volume of calls, particularly at night
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Work with policing to consider how 20,000 additional police officers will be allocated across forces and functions.
  Stated by Kit Malthouse MPStated in progress
2. Action
  Continue ensuring that police receive the resources needed to carry out their work and address financial pressures.
  Stated by Kit Malthouse MPStated in progress
3. Action
  Escalate calls raising particular concerns to supervisors so resources can be prioritised where possible.
  Stated by West Midlands PoliceStated completed
1. Action
  Involve the Force Incident Manager during exceptionally busy response shifts to enable redeployment of resources from outside the area where possible.
  Stated by West Midlands PoliceStated completed
2. Action
  Use a Log Closure Doctrine to support bolder dispatcher decisions and focus resources on calls with the most pressing needs.
  Stated by West Midlands PoliceStated completed
3. Action
  Reduce dispatcher log volumes by transferring logs over 24 hours old to another team.
  Stated by West Midlands PoliceStated completed
4. Action
  Change the dispatch model, including seating and interactions, to improve call handling efficiency.
  Stated by West Midlands PoliceStated completed
5. Action
  Change shift patterns to improve team relationships and the efficient handling and transfer of calls between shifts.
  Stated by West Midlands PoliceStated completed
6. Action
  Develop a new Command and Control platform to improve identification of resource availability and response times.
  Stated by West Midlands PoliceStated in progress
7. Action
  Monitor call response times, resolution, resource levels and performance to assess whether appropriate resources remain available.
  Stated by West Midlands PoliceStated in progress
Respondent positions 4
1. Position
  The 2019/20 police funding settlement is considered sufficient to meet financial pressures and fill capability gaps.
  Stated by Kit Malthouse MPExisting arrangements considered sufficient
1. Position
  Finite resources limit the ability to respond to all emergency calls within the appropriate time, despite prioritisation.
  Stated by West Midlands PoliceUnable to act
2. Position
  The incorrect call grading made no difference because limited resources meant a correctly graded P2 call would also not have received a response.
  Stated by Police and Crime Commissioner for West MidlandsDisputes the concern
3. Position
  Limited resources prevented West Midlands Police from reaching most P2 and some P1 calls during periods of exceptionally high demand.
  Stated by Police and Crime Commissioner for West MidlandsUnable to act
AI-generated summary

Karen Jane Burns · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Karen Jane Burns was found hanging from a basketball net at a park in Birmingham at 06.15 on 23 March 2019, after her ex-partner had reported that she had threatened to kill herself. The inquest concluded that her death was suicide. A serious concern was raised about West Midlands Police resources, particularly at night, and the incorrect grading and non-response of the call reporting the threat.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient resources to deal with the volume of calls, particularly at night
Wider context from the report
“1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. ”
Source location
Karen Jane Burns · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with policing to consider how 20,000 additional police officers will be allocated across forces and functions.

Verbatim wording from the response
“More recently, the Prime Minister announced an increase of 20,000 new police officers over the next three years, and the Home Office is working with policing to consider how these officers will be allocated across forces and functions. I hope that this response provides you with the reassurance that you seek but should you require further information please do not hesitate to contact me.”

Source location
2019-0273-Response-by-Home-Office
Page 2 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue ensuring that police receive the resources needed to carry out their work and address financial pressures.

Verbatim wording from the response
“Regarding resourcing levels in West Midlands Police, I would like to reassure you that public safety remains the Government’s number one priority and we will continue to ensure that the police are given the resources they need to do their important work. The police funding settlement for 2019/20 is significant and provides the most substantial investment in policing since 2010, with a total funding of up to £14 billion, an increase of up to £970m compared to 2018/19, including precept, pensions funding and national investment. This settlement enables policing to meet the financial pressures they face, while continuing to recruit and fill capability gaps.”

Source location
2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Escalate calls raising particular concerns to supervisors so resources can be prioritised where possible.

Verbatim wording from the response
“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Involve the Force Incident Manager during exceptionally busy response shifts to enable redeployment of resources from outside the area where possible.

Verbatim wording from the response
“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use a Log Closure Doctrine to support bolder dispatcher decisions and focus resources on calls with the most pressing needs.

Verbatim wording from the response
“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reduce dispatcher log volumes by transferring logs over 24 hours old to another team.

Verbatim wording from the response
“d. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by another team so dispatchers can concentrate only on the most critical calls without the distraction of managing older logs. Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Change the dispatch model, including seating and interactions, to improve call handling efficiency.

Verbatim wording from the response
“e. Changing the dispatch model, including where people sit and how they interact, to promote more efficient handling of calls.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Change shift patterns to improve team relationships and the efficient handling and transfer of calls between shifts.

Verbatim wording from the response
“f. Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a new Command and Control platform to improve identification of resource availability and response times.

Verbatim wording from the response
“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor call response times, resolution, resource levels and performance to assess whether appropriate resources remain available.

Verbatim wording from the response
“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The 2019/20 police funding settlement is considered sufficient to meet financial pressures and fill capability gaps.

Verbatim wording from the response
“Regarding resourcing levels in West Midlands Police, I would like to reassure you that public safety remains the Government’s number one priority and we will continue to ensure that the police are given the resources they need to do their important work. The police funding settlement for 2019/20 is significant and provides the most substantial investment in policing since 2010, with a total funding of up to £14 billion, an increase of up to £970m compared to 2018/19, including precept, pensions funding and national investment. This settlement enables policing to meet the financial pressures they face, while continuing to recruit and fill capability gaps.”

Source location
2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Finite resources limit the ability to respond to all emergency calls within the appropriate time, despite prioritisation.

Verbatim wording from the response
“3. The second and key issue that the Coroner raises is the risk created by the lack of resources available to West Midlands Police. On the night of 22/23 March 2019 most calls graded P2, and even some calls graded P1 (response time of 15 minutes), could not be reached due to the high level of demand and resources available.”

Source location
2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The incorrect call grading made no difference because limited resources meant a correctly graded P2 call would also not have received a response.

Verbatim wording from the response
“West Midlands Police has accepted that the call was incorrectly graded, which was recognised as human error. It has been discussed with the member of staff in question by management.”

Source location
2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
Page 1 · response
Published 18 October 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Limited resources prevented West Midlands Police from reaching most P2 and some P1 calls during periods of exceptionally high demand.

Verbatim wording from the response
“2. The risk created by the lack of resources available to West Midlands Police:”

Source location
2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
Page 1 · response
Published 18 October 2019
Open published response
6 Oct2014
Staffordshire South
Concerns raised1
1. Failure to dispatch Derbyshire officers immediately in urgent situations occurring on or close to the Staffordshire-Derbyshire border
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kai Lambe · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kai Lambe, aged 9, drowned in the River Dove after going down a salmon chute and sinking under the water. The report raises concern about a five-minute delay between Derbyshire receiving the emergency call and Staffordshire’s log commencing, and whether control room operators should dispatch officers immediately in urgent incidents on or near the county border.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to dispatch Derbyshire officers immediately in urgent situations occurring on or close to the Staffordshire-Derbyshire border
Wider context from the report
“At the inquest I heard helpful evidence from Inspector ████████ from your force. The incident which led to death took place in the River Dove which borders Staffordshire and Derbyshire. Because of local masts the initial 999 call went to Derbyshire. Derbyshire determined that the incident was in Staffordshire (emulating from the Staffordshire side of the River) and transferred the emergency call to Staffordshire. Staffordshire Officers then responded. Inspector Abbot indicated that this was in accordance with protocol although protocol does not necessarily have to be followed. There was a difference of 5 minutes between the time that the call was received by Derbyshire and the Staffordshire log commencing. In a case of a drowning child, 5 minutes can be very significant. I wonder if there is a training need for control room operators in Derbyshire to be aware to dispatch immediately Derbyshire Officers in urgent situations occurring on or close to the border between the 2 counties. ”
Source location
Kai Lambe · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Lack of safeguards preventing erroneous removal of priority logs from the dispatch queue

Failure to deploy a unit or add a significant update before removing a priority incident from the dispatch queue

Failure to ensure senior-officer endorsement and supervisory oversight of immediate and priority grade logs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Insufficient resources for timely allocation of police officers to priority cases

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to grade vulnerable incidents at the appropriate level

Insufficient police resources causing delays in attendance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Failure of police officers to attend incidents within policy timescales

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Inadequate resourcing and allocation of officers to grade 2 calls within an hour

Concerns raised4

Failure to resource and attend P2 incidents within 60 minutes during increased demand

Failure to deal with P2 incident logs within the required time

Inaccurate and incomplete monitoring of open and overdue P2 incident logs

Insufficient police officers to resource and attend P2 incidents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 2

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 6

Actions described in response 3

Actions described in response 12

Respondent positions 2