Recurring concern

Unreliable allocation and referral of welfare support between police and ambulance services

First to latest report 25 Jun 2018 — 25 May 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
10

What this concern includes

Includes failures in the bounded police-to-ambulance welfare-support interface, including unclear responsibility, inappropriate allocation of welfare checks, unfamiliar referral routes, delayed ambulance contact and arrangements that leave police providing welfare support that should be provided by the ambulance service.

What is not included
  • Excludes general ambulance response delays, ambulance capacity shortages or clinical ambulance triage failures where no police-to-ambulance welfare-support allocation or referral issue is identified.
  • Excludes routine non-urgent social-welfare checks allocated within social-care services when no police-to-ambulance welfare-support interface is involved.
  • Excludes generic inter-agency communication or coordination deficiencies without a specific welfare-concern allocation or referral context.
  • Excludes police assistance provided as part of an appropriate emergency response where the welfare-support allocation and referral arrangements are otherwise reliable.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire (Western)

    AI-generated summary

    Paul Andrew Alexander · 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

    Paul Andrew Alexander, who had a long-standing history of mental illness and was under the care of community mental health services, entered the water at Aspley Marina on 4 February 2024 and died from cold-water immersion. A welfare call to police was redirected to the ambulance service, which did not attend, and no emergency services were dispatched. The principal concern was a gap in how emergency services respond to welfare calls under the Right Care Right Person framework.

    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

    Reliance on call takers to bring cross-agency welfare concerns to operational managers

    Wider context from the report

    “In the course of the evidence, it became apparent the police had introduced RCRP in September 2023. RCRP is a police initiative arising out of a national agreement but to be implemented by individual police forces. Little or no consultation with other agencies had taken place prior to the implementation of RCRP in September 2023.Whilst I heard evidence that meetings with other agencies now do take place, the specifics of Paul’s case and the broader issues it raises have not been discussed nor is there any understanding/agreement in place as to how such a situation would now be addressed. As much as the court was advised was that if a similar situation arose today, there may be a discussion between operational managers in the respective police and ambulance call centres, but that this would be reliant upon the matter being brought to the attention of those respective managers by the call taker. The evidence from the RCRP lead at the ambulance service indicated the scenario that arose with Paul was not an isolated example. As such there appears to be a lacuna in how emergency services will respond to such a situation when it was accepted this was a call expressing concern for Paul’s welfare. ”

    Source location

    Paul Andrew Alexander · 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

    Train contact-centre staff, supervisors, and managers on Right Care Right Person and escalation procedures through peer training and updated training packages.

    Verbatim wording from the response

    “• Contact Focus Group established (November 2023) trained to deliver peer to peer training on RCRP – delivered updated training across Contact teams (July 2024)”

    Source location

    Response from West Yorkshire Police
    Page 5 · response
    Published 29 May 2025

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    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 and operate a widened WYP–YAS escalation process with approved procedures, digital documentation, daily review, and monthly partnership learning meetings.

    Verbatim wording from the response

    “4.1.5 This updated policy reflects discussions with partnership agencies, including a revised escalation process which was discussed with YAS in September 2024. Since this date, WYP have been in regular contact with YAS to develop and introduce an improved escalation process to streamline and widen the scope of escalation to support in cases where the RCRP threshold to deploy is not met.”

    Source location

    Response from West Yorkshire Police
    Page 6 · response
    Published 29 May 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

    West Yorkshire Police states RCRP did not change existing processes, which were already governed by established welfare and escalation policies.

    Verbatim wording from the response

    “4.1.1 There has been an existing ‘Escalation Policy’ in force prior to the launch of RCRP, contained within the ‘Welfare check deployment criteria’ Policy, which was updated in consultation with YAS in August 2022.”

    Source location

    Response from West Yorkshire Police
    Page 5 · response
    Published 29 May 2025

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · 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

    Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his death.

    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 call an ambulance promptly following a concern for welfare call

    Wider context from the report

    “2) Information sharing between SWAST and D&CP. A number of issues were revealed during the course of the evidence. a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours. b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate. c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.) d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached. e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options. f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial? ”

    Source location

    Lachlan Charles Campbell · 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

    Train officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.

    Verbatim wording from the response

    “As a part of RCRP, if our police officers come across or attend an incident in respect of which they deem that there is a requirement for additional medical support, they are trained to telephone 999 from the scene. This is to seek to ensure that the 999 operator can liaise directly with the person who has the patient with them and can offer appropriate treatment, as well as allocating a resource to attend.”

    Source location

    Response from Devon and Cornwall Police
    Page 2 · response
    Published 4 March 2025

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    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 officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.

    Verbatim wording from the response

    “If our officers call for an ambulance through the police control room, they are asked if there is a reason that they cannot do this themselves (such as the need to commence CPR, or other environmental factors). Police control room and SWAST personnel are trained to record all relevant information when contacting or otherwise liaising with SWAST.”

    Source location

    Response from Devon and Cornwall Police
    Page 2 · response
    Published 4 March 2025

    Open published response

  3. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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

    Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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

    Unclear and delayed police-to-ambulance referral process for welfare concerns

    Wider context from the report

    “In this case GMP did not call NWAS and asked the nurses to contact NWAS. The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with. This also led to a delay in the call being made. ”

    Source location

    Mr Gregory Rekowski · 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

    Review, revise and enhance multi-agency procedures through sessions involving all named partner organisations.

    Verbatim wording from the response

    “Several distinct sessions were convened to review, revise and enhance our existing procedures from multiple perspectives. These sessions each included insight and oversight from all partner organisations named in this letter.”

    Source location

    2018-0411-Response-by-GMCA
    Page 2 · response
    Published 28 December 2018

    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 pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.

    Verbatim wording from the response

    “We have now drawn together a pan-GM protocol for response, developed specifically in order to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk; and to promote communication and escalation at the first point that a common understanding may falter.”

    Source location

    2018-0411-Response-by-GMCA
    Page 3 · response
    Published 28 December 2018

    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

    Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.

    Verbatim wording from the response

    “Clearly, it is one thing to develop protocols, and quite another to embed them across the workforce. For this reason, we will now seek to embed these protocols within their respective agencies. I will ask them to agree to do so at a coming meeting of a new GM Responding to Crisis Board – a meeting I have convened in part in response to a common desire all partners have to enhance our broader offer around members of the community confronted with such risk. This Board will hold responsibility as part of its work programme for ensuring that these protocols are cascaded, rooted, and delivered upon.”

    Source location

    2018-0411-Response-by-GMCA
    Page 3 · response
    Published 28 December 2018

    Open published response

  4. South Wales Central

    AI-generated summary

    Mr Richard Thomas Peter Barrett · 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

    On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.

    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 request police assistance for welfare checks when ambulance resources are constrained

    Wider context from the report

    “(4) The police could have been asked to perform a welfare check. Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival. ”

    Source location

    Mr Richard Thomas Peter Barrett · 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

    Raise overdose welfare checks with police and seek a formal memorandum-of-understanding extension.

    Verbatim wording from the response

    “We have a memorandum of understanding with the Police which does specify circumstances in which the Trust should contact the Police. Welfare checks are not included within that document. The Trust does meet with the Police as part of the joint emergency services network. The Trust will raise this issue with the Police at these joint meetings and seek an increase to the specific circumstances to include overdose cases. We will write to you further once that meeting has taken place and update in relation to the matter.”

    Source location

    2018-0249-Response-by-University-Health-Board
    Page 5 · response
    Published 24 September 2018

    Open published response

  5. West Sussex

    AI-generated summary

    MARGARET STEMP · 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

    Margaret Stemp, aged 91, was found deceased on 28 December 2017 after she and her sister had fallen and remained on the floor for over seven hours before police assistance. The inquest concluded that she died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention. Concerns included insufficient ambulance resources, reliance on police for welfare support, failure to recognise worsening circumstances, and no clinical oversight of the decision to stand down the ambulance response.

    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

    Reliance on Police to provide necessary welfare support

    Wider context from the report

    “(2) That the Police had to be used to provide the necessary welfare support to these ladies ”

    Source location

    MARGARET STEMP · 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

    Implement procedures safeguarding fallen patients’ welfare while they await an ambulance.

    Verbatim wording from the response

    “I am grateful to the Police for their assistance on this occasion, however I fully accept that the welfare of patients is SECAmb’s responsibility, not that of the Police. Since this incident, we have put in place new procedures to ensure the welfare of patients who have fallen and to whom we are not able to respond in a timely manner. I attach a copy of our Emergency Operations Centre clinical summary (and relevant attachments) setting out our new procedure to safeguard the welfare of patients who have fallen, while they are awaiting an ambulance.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    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 Patient Welfare Procedure requiring Support Call Takers to work with Clinical Navigators to manage waiting calls clinically.

    Verbatim wording from the response

    “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026