PFD report

Rebecca Alice Fisher · Prevention of Future Deaths report

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Issued 15 May 2023•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Lack of understanding of how to apply golden hour guidance and its required timescales
    Part of recurring concern: Unreliable missing-person response
  2. Poor-quality documentation and information sharing between officers and supervision
    Part of recurring concern: Unreliable circulation of safety-critical mental health information
  3. Lack of monitoring of effective Aide Memoire use and implementation
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Review whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  2. Action

    Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023.
  3. Action

    Disseminate guidance that mobile-phone tracing and cell-site enquiries should be considered for medium- and high-risk missing persons, with rationale recorded when not pursued.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Cost to GMP must never justify not using mobile phone data for medium- or high-risk missing persons.

    Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of understanding of how to apply golden hour guidance and its required timescales

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Poor-quality documentation and information sharing between officers and supervision

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable circulation of safety-critical mental health information.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of monitoring of effective Aide Memoire use and implementation

Wider context from the report

“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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unclear effectiveness of missing-person training in supporting high-risk assessments

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of understanding that short periods away from mental health units do not preclude high-risk status when a patient fails to return

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable objective criteria for safety risk assessment.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Poor understanding of the high-risk status of voluntary mental health ward patients who fail to return

Wider context from the report

“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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of understanding of how to access mobile phone data such as cell site data

Wider context from the report

“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. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

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 whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.

Verbatim wording from the response

“To further address this issue across the organisation, the professional standards branch referred the matter to GMP’s training school, as it was recognised that supervisors who have been substantive for a long period of time may not have had any recent training or continuous professional development (CPD) with regards to investigating missing persons, Golden Hour tasks and risk assessments.”

Source location

Response from Greater Manchester Police
Page 4 · response
Published 17 May 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

Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.

Verbatim wording from the response

“The MPSU are also sending a notification to all operational Superintendents across the Force to state that the Golden Hour principles guidance is included within operational briefings alongside information regarding the cost of cell siting. The briefings will also include a reminder to operational Sergeants to keep the next of kin and family of the missing person updated, as per the concern raised in point four and include details of this case as an example of the importance of correct risk assessment and understanding of mental health terminology.”

Source location

Response from Greater Manchester Police
Page 4 · response
Published 17 May 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

Disseminate guidance that mobile-phone tracing and cell-site enquiries should be considered for medium- and high-risk missing persons, with rationale recorded when not pursued.

Verbatim wording from the response

“Specifically on the Stockport District, the Senior Leadership Team have already circulated a notification to all response supervisors to ensure that they are aware that cell citing, and mobile phone enquiries should be considered for medium risk missing persons, as well as high risk missing persons if relevant. If supervisors are not going to pursue an avenue of investigation, they should have a proper rationale to explain why it is not a proportionate enquiry and this should be recorded on the MFH report. This was also sent out to all District Commanders by the MPSU.”

Source location

Response from Greater Manchester Police
Page 3 · response
Published 17 May 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

Create and distribute a communications-data guide covering Cycomms, mobile-phone enquiries, and access for medium- and high-risk missing persons.

Verbatim wording from the response

“Cycomms, cell siting, and mobile phone enquiries should be considered for medium and high-risk missing persons. A notification is also being sent out on the Organisation Learning Hub Top three bulletin June 2023 edition. Item one of the bulletin is regarding analysing communications data, and this covers the use of Cycomms and Mobile phone enquiries. A comprehensive guide has been created to address the learning around a lack of knowledge of this area. The bulletin will specifically detail that all communications data can be sought for medium and high risk missing, and a guide will direct officers on how to do this. The Organisation Learning Hub Top three bulletin goes to every member of staff and officer within GMP.”

Source location

Response from Greater Manchester Police
Page 4 · response
Published 17 May 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

Re-circulate the Missing from Home Policy 2022 and Aide Memoires through existing continuous professional development channels.

Verbatim wording from the response

“GMP are in the process of re-circulating the MFH Policy 2022 and Aide Memoires. These have already been shared through the CPD sessions that have been provided by the MPSU.”

Source location

Response from Greater Manchester Police
Page 5 · response
Published 17 May 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

Develop and disseminate a seven-minute briefing on mental-health terminology, associated risk, Golden Hour principles, communications data, costs, and Aide Memoire use.

Verbatim wording from the response

“GMP want to ensure that its staff and officers understand the terminology used by mental health services for voluntary mental health patients and for those who have unescorted leave. To address this, I have asked the Organisational Learning Development Group (OLDG) to produce a seven-minute briefing. A seven-minute briefing is widely used across organisations as research suggests that seven minutes is an ideal time span to concentrate and learning is more memorable, as it is simple and not clouded by other issues and pressures. It is delivered in a flow chart form, in person by supervisors. This format also allows the recipients to ask questions following the briefing to confirm their understanding.”

Source location

Response from Greater Manchester Police
Page 2 · response
Published 17 May 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

Determine and implement a method to measure staff understanding and the briefing’s effectiveness.

Verbatim wording from the response

“I want to ensure that officers and staff understand the new information being presented to them within the briefing and that they can effectively apply this in their everyday role when investigating a missing person. To achieve this, the OLDG are currently exploring the most effective way to monitor their understanding. There are several options available which are being considered.”

Source location

Response from Greater Manchester Police
Page 2 · response
Published 17 May 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

Monitor completion of the actions identified in the Regulation 28 response through the Strategic Learning Board.

Verbatim wording from the response

“GMP is committed to constantly improving its response to Missing People. It is vital we learn lessons in such tragic cases. The strategic lead for safeguarding will put out immediate instructions to all district leads regarding the learning in this case and highlight the Golden Hour tasks that must be completed by all staff.”

Source location

Response from Greater Manchester Police
Page 7 · response
Published 17 May 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

Circulate an interim memorandum to District Commanders for dissemination on mental-health terminology, risk, Golden Hour tasks, and mobile-phone data access.

Verbatim wording from the response

“Whilst this briefing package is being designed by the OLDG, GMP have, in the short term, circulated a memorandum to all District Commanders explaining the issues highlighted from this inquest and an explanation of the terminology used in mental health settings and previous misconception of risk. The notification also includes the information detailed within the response to point three below regarding golden hour tasks and a lack of understanding around the cost of accessing mobile phone data. The District Commanders will then disseminate this to their divisional supervisors and colleagues.”

Source location

Response from Greater Manchester Police
Page 3 · response
Published 17 May 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

Review the Missing from Home Policy wording on medium-risk Golden Hour timescales and consider clarification.

Verbatim wording from the response

“I have consulted with the MPSU, and they are going to consider this terminology and will be explaining it further to aid the officers understanding of what time frame this refers to.”

Source location

Response from Greater Manchester Police
Page 3 · response
Published 17 May 2023

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

Cost to GMP must never justify not using mobile phone data for medium- or high-risk missing persons.

Verbatim wording from the response

“The cost to GMP to access mobile phone data and using cell siting should never be a reason as to why it is not used. The inquest highlighted a lack of understanding from some officers about this being a reason as to why GMP may not use cell siting. This is incorrect. Operational Superintendents will be informed of this via the notification from the Missing Person Safeguarding Unit and they will be asked to disseminate this information to their respective supervisors and teams across all districts to ensure that officers and staff are not considering this as a factor in their decision making. This would also ensure it is not cited as a reason to members of the public as to why GMP would not utilise mobile phone data.”

Source location

Response from Greater Manchester Police
Page 4 · response
Published 17 May 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026