South Yorkshire Police
Police / Law Enforcement
Action Taken
• A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. • A mandatory task has been embedded within Compact, our MFH management system, providing officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form. • A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light. (AI summary)
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Dear Madam Coroner, Response to Regulation 28 report in respect of deceased Roger Gary LEADBEATER Thank you for your letter dated 27th January 2026 and the corresponding Regulation 28 report where you raise one matter of concern. This matter is in relation to the arrangements for the physical handover of missing persons who are subsequently transferred to a medical facility or to another police force. South Yorkshire Police seek all opportunities to identify opportunities to learn and improve its response to those we serve. Whilst work had already been ongoing to improve this response, upon receipt of this Regulation 28 preventing future deaths notice I directed a thorough review around the actions of South Yorkshire Police. I wish to provide you with a detailed account of the actions we have taken to strengthen our procedures, the governance now in place to ensure compliance and the steps we are taking to support wider learning beyond this force. Implementation of the Revised Handover Process Several substantive measures have now been introduced:
• Dedicated Handover form — A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. This form has been uploaded to the central repository on the Missing from Home (MFH) SharePoint portal to ensure universal accessibility and version control.
• System-Integrated prompts — A mandatory task has been embedded within Compact, our MFH management system. This provides officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form, reducing the risk of omission and ensuring a consistent workflow.
• Force-Wide communications — A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light. This has ensured that all officers and staff understand both the procedural requirements and the moral imperative underpinning them.
• Governance-Level briefing — The thematic lead for MFH briefed the Missing Governance Meeting, comprising of Inspectors and Sergeants, to ensure that supervisory leaders are fully sighted on the new arrangements and are equipped to drive compliance at a local level.
• Tactical-Level briefing —Further briefings have been conducted at the tactical meeting attended by MFH officers. This has reinforced operational understanding and provided an opportunity for officers to seek clarification and raise practical considerations.
Assurance, Monitoring and Embedding To ensure that the revised process becomes fully embedded and consistently applied, the following assurance mechanisms have been established:
• MFH Officer quality assurance — as part of their existing responsibilities, MFH officers will review the Compact tasks associated with each case. Where the handover form has not been completed, they will escalate the matter in line with the established VA/VC escalation process.
• Supervisory review by Inspectors and Sergeants — supervisors will check the completion of the handover form during their routine review of MFH cases. This ensures that compliance is monitored at multiple levels and that any gaps are identified promptly.
• Audit of documentation quality — MFH officers will assess the quality and completeness of the information recorded on the form to ensure it meets the required standard and provides an accurate and reliable record of the handover.
• Structured Feedback Loop — ongoing feedback will be gathered from team leads and operational officers to identify any areas of misunderstanding, procedural friction, or opportunities for refinement.
• Governance Review — the revised process was reviewed at the governance meeting to confirm it is operating as intended and to agree any further improvements that may be necessary. National Learning Initial benchmarking undertaken by the force suggests this may represent a wider national gap in practice. In the interests of supporting broader learning and improving safeguarding arrangements across policing, the thematic lead has contacted the national Lead Staff Officer and will be presenting this work at a forthcoming national MFH quarterly meeting. The intention is to encourage consideration of this process as a potential model for national best practice. I hope this update provides reassurance that the force has taken the issues raised during the inquest with the utmost seriousness and has acted to address them.
• Dedicated Handover form — A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. This form has been uploaded to the central repository on the Missing from Home (MFH) SharePoint portal to ensure universal accessibility and version control.
• System-Integrated prompts — A mandatory task has been embedded within Compact, our MFH management system. This provides officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form, reducing the risk of omission and ensuring a consistent workflow.
• Force-Wide communications — A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light. This has ensured that all officers and staff understand both the procedural requirements and the moral imperative underpinning them.
• Governance-Level briefing — The thematic lead for MFH briefed the Missing Governance Meeting, comprising of Inspectors and Sergeants, to ensure that supervisory leaders are fully sighted on the new arrangements and are equipped to drive compliance at a local level.
• Tactical-Level briefing —Further briefings have been conducted at the tactical meeting attended by MFH officers. This has reinforced operational understanding and provided an opportunity for officers to seek clarification and raise practical considerations.
Assurance, Monitoring and Embedding To ensure that the revised process becomes fully embedded and consistently applied, the following assurance mechanisms have been established:
• MFH Officer quality assurance — as part of their existing responsibilities, MFH officers will review the Compact tasks associated with each case. Where the handover form has not been completed, they will escalate the matter in line with the established VA/VC escalation process.
• Supervisory review by Inspectors and Sergeants — supervisors will check the completion of the handover form during their routine review of MFH cases. This ensures that compliance is monitored at multiple levels and that any gaps are identified promptly.
• Audit of documentation quality — MFH officers will assess the quality and completeness of the information recorded on the form to ensure it meets the required standard and provides an accurate and reliable record of the handover.
• Structured Feedback Loop — ongoing feedback will be gathered from team leads and operational officers to identify any areas of misunderstanding, procedural friction, or opportunities for refinement.
• Governance Review — the revised process was reviewed at the governance meeting to confirm it is operating as intended and to agree any further improvements that may be necessary. National Learning Initial benchmarking undertaken by the force suggests this may represent a wider national gap in practice. In the interests of supporting broader learning and improving safeguarding arrangements across policing, the thematic lead has contacted the national Lead Staff Officer and will be presenting this work at a forthcoming national MFH quarterly meeting. The intention is to encourage consideration of this process as a potential model for national best practice. I hope this update provides reassurance that the force has taken the issues raised during the inquest with the utmost seriousness and has acted to address them.