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Investigation and inquest
On the 2nd February 2021 I commenced an investigation into the death of Angeline Marie Phillips, 35 years, born on the 20th December 1985. The investigation concluded at the end of the inquest on the 5th December 2022.
The medical cause of death of Angeline Marie Phillips was:
1a) ████████ Toxicity
The conclusion of the investigation at the Inquest was Misadventure.
Circumstances of the death
1) Angeline Marie Phillips (hereinafter referred to as “the Deceased”) died on the 30th January 2021 at her home address at 2 Wilbraham Road, Walkden, Manchester.
2) The Deceased was found having died at her home address at 03.48 hours on the 30th January 2021, having had no contact with family or friends after 19.44 hours on the 28th January 2021.
3) On the 29th of January 2021 at 18.09 hours a friend of the Deceased contacted Greater Manchester Police by telephone and reported a concern for the welfare of the Deceased. The friend confirmed that the Deceased had been in and out of Hospital (both Salford Royal Hospital and the Royal Bolton Hospital) in the previous week following on from numerous suicide attempts. The home address of the Deceased was given to the Police as 2 Wilbraham Road, Walkden, Manchester.
4) The Call Handler graded the priority response to the reported incident under the Greater Manchester Response Policy, which was last amended to Version 1.4 on the 24th June 2019. The response was graded as Grade 2 Priority Response, which requires the radio operator to allocate the incident within 20 minutes and attendance within 1 hour from the creation of the Incident Log.
5) A police officer did not attend 2 Wilbraham Road, Walkden, Manchester and at 20.28 hours on the 29th January 2021 a Sargent, who was the Command and Control Supervisor, made a decision that the incident was a medical matter and the North West Ambulance Service (hereinafter referred to as “NWAS”) needed to deal with the incident. The incident was reported to NWAS at 20.32 hours.
6) NWAS attended the Deceased’s home address at 23.06 hours and confirmed that there was no answer at the address or from any contact numbers and the Ambulance crew had left the address to attend another incident.
7) At 00.03 hours on the 30th January 2021 the Command and Control Supervisor noted the Incident Log “For Allocation” but a Police officer still did not attend the address at 2 Wilbraham Road, Walkden, Manchester until entry to the address was forced at 03.48 hours by police officers and the deceased was found having died in the property.
Coroner’s concerns
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.
2) I request that you conduct a review of the following concerns
a) 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.
b) When the review has taken place implement to consider the implementation of a training programme for all police officers and civilian staff involved in the operating procedures referred to in the Greater Manchester Police Incident Response Policy
Information checked against the published report and official responses