Rebecca Alice Fisher · Prevention of Future Deaths report

On 19th April 2022 I commenced an investigation into the death of Rebecca Alice Fisher. The investigation concluded on the 18th April 2023 and the conclusion was one of Suicide. The medical cause of death was 1a) Drug Toxicity.

On 15th April 2022, Rebecca Alice fisher was found deceased by her family in a secluded area of Reddish Vale. Post-mortem examination included toxicology. She had a fatal dose of drugs in her system including pregabalin. ████████
████████ Rebecca had been reported by the Norbury Ward to Greater Manchester Police (GMP) as a high-risk missing person on the 11th April at about 6pm after she failed to return from 30 minutes of unescorted leave. Rebecca had a complex mental health history ████████
████████ She had been admitted to the Norbury ward as a crisis patient. ████████
████████ She had been allowed to leave for 30 minutes of unescorted leave. It was recognised that this presented a risk. Her failure to return was correctly assessed by hospital staff as creating an escalated risk and a high-risk situation. Greater Manchester Police failed to correctly assess her as a high-risk missing person. As a consequence, this meant that mobile telephone enquiries were not immediately undertaken, and the investigation did not have specialised input in the hours immediately following her being reported missing. It is probable that if these enquiries had taken place Greater Manchester Police would have known she was in the area of her home address and Reddish Vale. It is possible that Rebecca would have been found before she died had she been treated as a high-risk missing person.

The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:

1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.

The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.

Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.