PFD report

Karen Jane Burns · Prevention of Future Deaths report

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Issued 12 Aug 2019•Birmingham and Solihull

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
15

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 raised2

  1. Insufficient resources to deal with the volume of calls, particularly at night
    Part of recurring concern: Unreliable police incident dispatch and response under service demand
  2. Failure to grade calls correctly
    Part of recurring concern: Unsafe emergency call handling
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.14

  1. Action

    Work with policing to consider how 20,000 additional police officers will be allocated across forces and functions.

    Stated by Kit Malthouse MPStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  2. Action

    Ask Home Office officials to contact West Midlands Police to identify remedial or additional measures for appropriate 101 call handling.

    Stated by Kit Malthouse MPStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  3. Action

    Continue ensuring that police receive the resources needed to carry out their work and address financial pressures.

    Stated by Kit Malthouse MPStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Police and Crime Commissioners and Chief Constables are responsible for deciding public communications and incident responses in their forces.

    Stated by Kit Malthouse MPRedirects 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

Insufficient resources to deal with the volume of calls, particularly at night

Wider context from the report

“1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. ”

Is this part of a recurring concern?

Yes — Unreliable police incident dispatch and response under service demand.

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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 grade calls correctly

Wider context from the report

“1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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

Work with policing to consider how 20,000 additional police officers will be allocated across forces and functions.

Verbatim wording from the response

“More recently, the Prime Minister announced an increase of 20,000 new police officers over the next three years, and the Home Office is working with policing to consider how these officers will be allocated across forces and functions. I hope that this response provides you with the reassurance that you seek but should you require further information please do not hesitate to contact me.”

Source location

2019-0273-Response-by-Home-Office
Page 2 · response
Published 18 October 2019

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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

Ask Home Office officials to contact West Midlands Police to identify remedial or additional measures for appropriate 101 call handling.

Verbatim wording from the response

“On the concern of 101 call grading and prioritisation, Elected Police and Crime Commissioners and Chief Constables are responsible for deciding how best to manage their communications with the public, and how to respond to incidents in their force areas. However, I will ask Home Office officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately.”

Source location

2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019

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 ensuring that police receive the resources needed to carry out their work and address financial pressures.

Verbatim wording from the response

“Regarding resourcing levels in West Midlands Police, I would like to reassure you that public safety remains the Government’s number one priority and we will continue to ensure that the police are given the resources they need to do their important work. The police funding settlement for 2019/20 is significant and provides the most substantial investment in policing since 2010, with a total funding of up to £14 billion, an increase of up to £970m compared to 2018/19, including precept, pensions funding and national investment. This settlement enables policing to meet the financial pressures they face, while continuing to recruit and fill capability gaps.”

Source location

2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019

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

Capture learning from the incident and provide training to the involved call handlers.

Verbatim wording from the response

“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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 THRIVE+ training for staff using learning from the incident.

Verbatim wording from the response

“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Involve the Force Incident Manager during exceptionally busy response shifts to enable redeployment of resources from outside the area where possible.

Verbatim wording from the response

“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019

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 calls raising particular concerns to supervisors so resources can be prioritised where possible.

Verbatim wording from the response

“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019

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 a new Command and Control platform to improve identification of resource availability and response times.

Verbatim wording from the response

“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Change the dispatch model, including seating and interactions, to improve call handling efficiency.

Verbatim wording from the response

“e. Changing the dispatch model, including where people sit and how they interact, to promote more efficient handling of calls.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Provide ongoing further training to all control room staff to reduce call-grading errors.

Verbatim wording from the response

“training for all control room staff is ongoing to ensure such errors are eliminated as far as possible. It is clear from the Coroner’s findings that the wrong grading of this call made no difference to the deceased in this case since even a correctly graded P2 call would not have been responded to due to pressure on resources on the night of 22/23 March 2019.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019

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

Reduce dispatcher log volumes by transferring logs over 24 hours old to another team.

Verbatim wording from the response

“d. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by another team so dispatchers can concentrate only on the most critical calls without the distraction of managing older logs. Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Change shift patterns to improve team relationships and the efficient handling and transfer of calls between shifts.

Verbatim wording from the response

“f. Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Use a Log Closure Doctrine to support bolder dispatcher decisions and focus resources on calls with the most pressing needs.

Verbatim wording from the response

“5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019

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 call response times, resolution, resource levels and performance to assess whether appropriate resources remain available.

Verbatim wording from the response

“6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 3 · response
Published 18 October 2019

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

Police and Crime Commissioners and Chief Constables are responsible for deciding public communications and incident responses in their forces.

Verbatim wording from the response

“On the concern of 101 call grading and prioritisation, Elected Police and Crime Commissioners and Chief Constables are responsible for deciding how best to manage their communications with the public, and how to respond to incidents in their force areas. However, I will ask Home Office officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately.”

Source location

2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019

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 2019/20 police funding settlement is considered sufficient to meet financial pressures and fill capability gaps.

Verbatim wording from the response

“Regarding resourcing levels in West Midlands Police, I would like to reassure you that public safety remains the Government’s number one priority and we will continue to ensure that the police are given the resources they need to do their important work. The police funding settlement for 2019/20 is significant and provides the most substantial investment in policing since 2010, with a total funding of up to £14 billion, an increase of up to £970m compared to 2018/19, including precept, pensions funding and national investment. This settlement enables policing to meet the financial pressures they face, while continuing to recruit and fill capability gaps.”

Source location

2019-0273-Response-by-Home-Office
Page 1 · response
Published 18 October 2019

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

Finite resources limit the ability to respond to all emergency calls within the appropriate time, despite prioritisation.

Verbatim wording from the response

“3. The second and key issue that the Coroner raises is the risk created by the lack of resources available to West Midlands Police. On the night of 22/23 March 2019 most calls graded P2, and even some calls graded P1 (response time of 15 minutes), could not be reached due to the high level of demand and resources available.”

Source location

2019-0273-Response-by-West-MIdlands-Police
Page 2 · response
Published 18 October 2019

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

Limited resources prevented West Midlands Police from reaching most P2 and some P1 calls during periods of exceptionally high demand.

Verbatim wording from the response

“2. The risk created by the lack of resources available to West Midlands Police:”

Source location

2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
Page 1 · response
Published 18 October 2019

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 incorrect call grading made no difference because limited resources meant a correctly graded P2 call would also not have received a response.

Verbatim wording from the response

“West Midlands Police has accepted that the call was incorrectly graded, which was recognised as human error. It has been discussed with the member of staff in question by management.”

Source location

2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
Page 1 · response
Published 18 October 2019

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.1

  1. 1

    Hold West Midlands Police to account for embedding existing changes and undertaking further work to mitigate recurrence.

    Stated by Police and Crime Commissioner for West MidlandsStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.

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

Hold West Midlands Police to account for embedding existing changes and undertaking further work to mitigate recurrence.

Verbatim wording from the response

“I will be holding West Midlands Police to account to ensure that the changes they have already made are fully embedded and further work is done to mitigate an incident like this happening again.”

Source location

2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
Page 3 · response
Published 18 October 2019

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