Recurring concern

Unsafe implementation of Right Care, Right Person attendance decisions

First to latest report 27 May 2025 — 1 Dec 2025

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
8

What this concern includes

Includes failures of the named Right Care, Right Person implementation and attendance-decision process, including decision review arrangements, timeliness safeguards, operational guidance and public communications where these affect whether time-sensitive attendance is appropriately sought, considered or provided.

What is not included
  • Excludes generic police or emergency-service attendance delays where the Right Care, Right Person process is not identified.
  • Excludes ordinary resource shortages, call handling or emergency response failures that are unrelated to Right Care, Right Person attendance decisions.
  • Excludes generic public communication deficiencies not specifically concerning implementation of Right Care, Right Person.
  • Excludes downstream clinical or rescue failures after an appropriate attendance decision has been made.

Reports and published responses 3 reports

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

  1. Manchester South

    AI-generated summary

    Lewis Bates · 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

    Lewis Bates was reported missing after leaving his mother and stepfather’s house, having previously expressed an intention to end his life if he could not see his children. His body was found approximately two hours and 21 minutes after the missing-persons report. Concerns included the absence of guidance for call handlers about reasonable enquiries, advice to contact healthcare providers, and apparent confusion about the applicable police response process.

    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 correctly distinguish between missing-person reporting and the Right Person Right Care initiative

    Wider context from the report

    “3. Having considered the audio recording and transcript of the 999 call with the utmost care, I am concerned that the call handler appears confused as to whether she was dealing with the call as a missing persons report or under the Right Person Right Care initiative. I am concerned such confusion was a relevant factor in the appropriate police response to the 999 call not being provided on this occasion. ”

    Source location

    Lewis Bates · 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 Missing Person and RCRP policies, consult stakeholders, and progress senior-officer sign-off to clarify their distinction and reduce operational confusion.

    Verbatim wording from the response

    “GMP will conduct a full review of both the Missing Person and RCRP policies to identify areas of overlap and potential confusion. Following this review and wherever appropriate:”

    Source location

    Response from Greater Manchester Police
    Page 3 · response
    Published 3 December 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

    Deliver enhanced call-handler and supervisor training on vulnerability assessment, complex cases, escalation decisions, and supervisory quality assurance.

    Verbatim wording from the response

    “Rather than imposing rigid lists, GMP will strengthen decision-making through enhanced training and guidance for call handlers. This will include:”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 3 December 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

    Update the FCCO Sherlock guidance system with revised instructions for distinguishing Missing Person and RCRP procedures.

    Verbatim wording from the response

    “Alongside the re-publication of amended policies, the Public Protection Division will work closely with the Force Contact, Crime and Operations (FCCO) Branch to ensure that revised guidance is made available to all call handlers and their supervisors. This will be delivered to respective teams and police staff via additional training. This measure is designed to prevent any further confusion and ensure consistency in decision-making.”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 3 December 2025

    Open published response

  2. Manchester North

    AI-generated summary

    Katie Overd · 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

    Katie Overd, aged 46, died at home on 20 March 2025. The inquest concluded that she died from an unintended overdose of prescribed medication against a background of longstanding inappropriate prescribing and delayed medication reduction. The report raised concern that the lack of proactive public communication about the Right Care Right Person process could delay families seeking assistance in emergencies.

    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 undertake proactive public communications about the implementation of Right Care Right Person

    Wider context from the report

    “1. There has been a decision made not to undertake any proactive public communications in relation to the implementation of Right Care Right Person. The court heard evidence this was both on a national and regional basis. As a result, the public who have significant concerns for the life of their family members may not seek assistance as quickly as they could do, labouring under the misapprehension that there will be a timely response from emergency services. ”

    Source location

    Katie Overd · 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

    Consider options with relevant agencies for addressing public and emergency-service access needs.

    Verbatim wording from the response

    “I therefore wanted to let you know that I will give further thought to this with the relevant agencies. For a number of reasons, we are not sure that a public message that might lead to a family calling a locksmith is the best response and so we wish to take the time to consider the various options that will best meet the needs of the public. I will be happy to share our thinking with you in due course if you wish.”

    Source location

    Response from Deputy Mayor of Greater Manchester
    Page 1 · response
    Published 20 October 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

    National public-facing communications are unnecessary because local inter-agency pathways triage calls and determine the appropriate responding service.

    Verbatim wording from the response

    “When the NPA was originally developed and agreed by all the signatories, a discussion took place regarding whether there should be national public facing communications in respect of which agency should deliver specific services. However, it was agreed and remains the position that when the public make calls for service, they will not necessarily know which service is the most appropriate to be responding to a call as the nature of an incident and the associated risks can vary significantly. It is for”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 20 October 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

    Existing call-handler routing is considered sufficient, so external communications need not specify which emergency service the public should call.

    Verbatim wording from the response

    “GMP’s (and my) view is that a member of the public might not be sure which would be the most appropriate emergency service to call, and so our processes are focussed on ensuring that the caller is routed to the most appropriate service to respond, no matter where a call is received. We would rather a member of public takes decisive action and calls “the emergency services” who can then, through training and experience, identify the most appropriate service to meet their needs (as per RC:RP) , rather than delay contact whilst they ponder which service is the right one to respond to the specific circumstances of their scenario – which itself may generate a delay.”

    Source location

    Response from RCRP Strategic Partnership Board
    Page 1 · response
    Published 20 October 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

    A public message encouraging families to call a locksmith is not being adopted because it may not be the best response for several reasons.

    Verbatim wording from the response

    “I therefore wanted to let you know that I will give further thought to this with the relevant agencies. For a number of reasons, we are not sure that a public message that might lead to a family calling a locksmith is the best response and so we wish to take the time to consider the various options that will best meet the needs of the public. I will be happy to share our thinking with you in due course if you wish.”

    Source location

    Response from Deputy Mayor of Greater Manchester
    Page 1 · response
    Published 20 October 2025

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Sophie Ann Louise Cotton · 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

    Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

    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

    Delays caused by supervisory review of negative “Right Care, Right Person” attendance decisions

    Wider context from the report

    “(4) Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time-sensitive. ”

    Source location

    Sophie Ann Louise Cotton · Prevention of Future Deaths report
    Page 3 · 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 authorise police attendance despite a reported real and immediate risk to life

    Wider context from the report

    “(1) During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life. ”

    Source location

    Sophie Ann Louise Cotton · 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 an initial intelligence-check process for every decision not to attend, followed by an expeditious supervisor review where non-attendance remains the decision.

    Verbatim wording from the response

    “Durham Constabulary recognises that there need to be safeguards within the system for speedy and timely reviews of decisions not to attend and 2 specific recommendations have been made to improve the current system. These recommendations have been approved and discussed with the College of Policing who have confirmed that they are in line with the National Toolkit for Right Care, Right Person (RCRP).”

    Source location

    Response from Durham Constabulary (2)
    Page 5 · response
    Published 29 May 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

    Escalate any second call about the same person within 12 hours to a supervisor for immediate further review, with additional calls subject to the same process.

    Verbatim wording from the response

    “On a second call about the same person within a 12 hour period where the answer on the first call was for the police not to attend there will be an immediate escalation to the Supervisor who will carry out a further review as soon as possible.”

    Source location

    Response from Durham Constabulary (2)
    Page 6 · response
    Published 29 May 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

    Collate concerns raised, review them against the toolkit and guidance, and amend the toolkit where necessary.

    Verbatim wording from the response

    “The College collates all information in respect of concerns that are raised, and reviews these against the toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary amendments will be made. The College continues to encourage forces to follow the guidance within their development of RCRP and provides ongoing support and advice to forces.”

    Source location

    Response from College of Policing
    Page 3 · response
    Published 29 May 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

    Continue reviewing toolkit content and provide forces with tools, training and support to implement and deliver Right Care, Right Person.

    Verbatim wording from the response

    “The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. The College continually reviews the content of the toolkit guidance to ensure forces are provided with the tools, training, and support to effectively implement and deliver RCRP.”

    Source location

    Response from College of Policing
    Page 3 · 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

    A review found no significant failings in the use or implementation of the Right Care Right Person policy.

    Verbatim wording from the response

    “A thorough review has since taken place and although it has not highlighted any significant failings in the use of, and implementation of the ‘Right Care Right Person’ (RCRP) policy, the review of the incident(s) has resulted in two specific points of organisational learning and recommendations to be implemented and progressed. Durham Constabulary has also consulted with the national mental health co-ordinator to ensure the response is aligned to national practice.”

    Source location

    Response from Durham Police and Crime Commissioner
    Page 1 · 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

    Operational decisions and responses under Right Care, Right Person are the responsibility of individual police forces, including Durham Constabulary.

    Verbatim wording from the response

    “In relation to the operational elements and decision-making processes, we have been in contact with Durham Constabulary and understand that a full response to these points is being provided.”

    Source location

    Response from College of Policing
    Page 1 · 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

    The information supplied during the 16:44 call did not indicate a real and immediate risk to life requiring police attendance.

    Verbatim wording from the response

    “At the time of the 16:44 call ████████ (mother) did express concerns about her daughter relaying information regarding previous incidents. The call handler asked if there had been any threats made on this occasion and was told that there had not been. Mrs Cotton states that she is probably overthinking but is worried about her daughter. There had not been any contact over the weekend and there was no new information from the previous call. Mrs Cotton confirms that her son is going to go back to the address again. It is confirmed to Mrs Cotton that on the information provided at that time that it is not considered that there is a real and immediate risk and that the police will not be attending. It is confirmed that the call will be subject to review by a supervisor as standard practice. All calls are assessed based upon the information supplied at the time of the call.”

    Source location

    Response from Durham Constabulary (2)
    Page 1 · response
    Published 29 May 2025

    Open published response

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

Back to top

Data last updated 7 September 2026