PFD report

Donna Constantine · Prevention of Future Deaths report

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Issued 19 Oct 2021•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
4

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
3

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 raised4

  1. Unavailability of verbatim recording for calls received by officers
    Part of recurring concern: Unreliable recording and preservation of safety-relevant telephone calls
  2. Lack of a clear escalation policy for calls received by officers from members of the community
  3. Failure to monitor officers’ work mobile phones when they are off duty or on annual leave
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Specific policing issues are for Greater Manchester Police, the National Police Chiefs’ Council and the College of Policing to address.

    Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Unavailability of verbatim recording for calls received by officers

Wider context from the report

“The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. ”

Is this part of a recurring concern?

Yes — Unreliable recording and preservation of safety-relevant telephone calls.

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 a clear escalation policy for calls received by officers from members of the community

Wider context from the report

“The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. ”

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

Failure to monitor officers’ work mobile phones when they are off duty or on annual leave

Wider context from the report

“The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. ”

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 a clear policy for creating an audit trail of actions taken on received calls

Wider context from the report

“The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Specific policing issues are for Greater Manchester Police, the National Police Chiefs’ Council and the College of Policing to address.

Verbatim wording from the response

“I acknowledge your concerns detailed in your report, and should stress that police forces are operationally independent and, as such, it is for the Greater Manchester Police, the National Police Chiefs Council and the College of Policing to address the specific issues raised about their ways of working as they relate to the inquest into the death of Ms Constantine. However, I can reassure you that the NPCC and CoP, who you have named in the report and have operational responsibilities, are aware of the recommendations and are working together to address them and respond within the requisite 56-day period.”

Source location

Response from Home Office
Page 1 · response
Published 21 October 2021

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 policing forces were not encouraged to provide officers’ mobile numbers as emergency or welfare-contact numbers.

Verbatim wording from the response

“The notice sets out your principal concern which highlights a text message sent by a vulnerable person to a Police Officer’s mobile phone which was not being monitored and your concern that giving out officer’s phone numbers to victims was a national policing approach.”

Source location

Response from NPCC
Page 1 · response
Published 21 October 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Continue liaising with the NPCC and College of Policing on developing policing policy.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 21 October 2021.
  2. 2

    Ensure the NPCC and College of Policing take forward their response to the recommendations.

    Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 21 October 2021.
  3. 3

    Update and introduce Victims Code provisions strengthening victim contact arrangements, single points of contact, decision explanations and support for vulnerable victims.

    Stated by College of Policing and National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 21 October 2021.

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 liaising with the NPCC and College of Policing on developing policing policy.

Verbatim wording from the response

“As a department I can advise we will continue to liaise with the NPCC and CoP on the development of policing policy and ensure that they take forward their response to your recommendations.”

Source location

Response from Home Office
Page 1 · response
Published 21 October 2021

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

Ensure the NPCC and College of Policing take forward their response to the recommendations.

Verbatim wording from the response

“As a department I can advise we will continue to liaise with the NPCC and CoP on the development of policing policy and ensure that they take forward their response to your recommendations.”

Source location

Response from Home Office
Page 1 · response
Published 21 October 2021

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 and introduce Victims Code provisions strengthening victim contact arrangements, single points of contact, decision explanations and support for vulnerable victims.

Verbatim wording from the response

“Firstly, it is important to note that since the death of Ms Constantine, the Victims Code was updated in April 2021, with a number of key changes having been introduced.”

Source location

Response from NPCC
Page 2 · response
Published 21 October 2021

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