Sophie Cotton

Dear Ms Sutton, Preventing Future Deaths Report – Sophie Ann Louise Cotton Thank you for providing the College of Policing with a copy of your report dated 27 May 2025 following the death of Sophie Ann Louise Cotton. We extend our sincere condolences to her family and all those affected. We have carefully considered the matters of concern raised in your report and provide the following response on behalf of the College of Policing.

1. During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life.

In relation to the operational elements and decision-making processes, we have been in contact with Durham Constabulary and understand that a full response to these points is being provided. Right Care Right Person (RCRP) is a national initiative that aims to ensure that vulnerable people get the right support from the right services. The College host the implementation toolkit for RCRP, which provides national guidance for all forces to follow., it applies to calls for service about:
• concern for the welfare of a person
• people who have walked out of a healthcare setting
• people who are absent without leave (AWOL) from mental health services
• medical incidents

RCRP has been developed under the National Partnership Agreement (NPA) which sets out the support of all key agencies including NPCC, Home Office, Department for Health & Social Care, NHS England, Association of Police and Crime Commissioners, and College of Policing. RCRP is based on the legal position that the police owe responsibility to take all reasonable measures to assist where there is either:

• a real and immediate risk to the life of a person (European Convention on Human Rights (ECHR) Article 2)
• a real and immediate risk of that person being subject to serious harm or other inhumane treatment (ECHR Article 3)

Where the legal thresholds are met, the police are under a duty to respond to incidents, and in addition, to respond to incidents involving crime. The College of Policing worked with the NPCC to create and publish the national Right Care Right Person implementation guidance toolkit. The section that specifically relates to the force control room can be found on the following link https://www.college.police.uk/guidance/right-care-right-person- toolkit/force-control-room-implementation-guidance

2. During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises.

The College RCRP guidance reaffirms the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no specific power of entry to carry out a concern for welfare check…’ The framework encourages forces to work with partners to identify any gaps in service, including to work with the Fire and Rescue Service, who have similar powers available to effect entry in emergency situations, and who have the appropriate skills, training and equipment to effect entry where necessary. However, based on the force’s risk assessment on the information known at the time, if the force’s assessment of risk does not amount to a risk to save life and limb, the police do not have a power to effect entry into a person’s home for the purpose of undertaking a welfare check. Ongoing monitoring and work is being undertaken with partners with regards to powers of entry to ensure all partners are aware of the legal parameters in which all agencies operate, including for all agencies to understand the specific legal powers available to them, and to ensure all options are being considered.

3. During the 16:57 call there was no decision for police to attend, even though this was the third caller (and second professional caller) that had expressed serious concerns about Sophie Cotton.

The toolkit outlines two separate routes for escalation processes covering ‘real-time escalation’, which is at the point of the call being received, as well as ‘partnership escalation’, which ensures partners have the ability to escalate concerns arising, especially where emerging themes are identified. The guidance advises forces to ‘to review the effectiveness and impact of RCRP, and to capture use of the escalation process.’ It is imperative that where decisions are subjected to an escalation process, and decisions have changed, that this is communicated to the call taker as soon as practicable.

The toolkit also provides advice and guidance to forces on their development and implementation of RCRP. As part of this guidance, it sets out that forces should ensure police officers and staff understand the interoperability between RCRP and non-RCRP-incidents and that policies are clear and easily accessible, specifically for control room staff and call handlers. Whilst the College sets out the national implementation guidance and toolkits for RCRP, it is for each force to undertake risk assessments in line with their own established control room procedures and force policy, as well as any agreements in place at a local level, when deciding which incidents they will respond to. The College collates all information in respect of concerns that are raised, and reviews these against the toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary amendments will be made. The College continues to encourage forces to follow the guidance within their development of RCRP and provides ongoing support and advice to forces.

4. Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time sensitive.

The College have been in contact with Durham Constabulary who have highlighted that they have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice in response to the concerns raised, to ensure efficiency and effectiveness in their response to calls for service. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. The College continually reviews the content of the toolkit guidance to ensure forces are provided with the tools, training, and support to effectively implement and deliver RCRP. We hope this reassures you of our continued commitment to supporting police forces in reviewing and refining operational processes and policies in response to concerns raised. Please do not hesitate to contact us should you require any further information.

1 Response to Regulation 28 Report for HM Coroner Relating to the Inquest Touching upon the Death of Ms Sophie Ann Louise Cotton CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- (1) During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life. Durham Constabulary Response At the time of the 16:44 call (mother) did express concerns about her daughter relaying information regarding previous incidents. The call handler asked if there had been any threats made on this occasion and was told that there had not been. Mrs Cotton states that she is probably overthinking but is worried about her daughter. There had not been any contact over the weekend and there was no new information from the previous call. Mrs Cotton confirms that her son is going to go back to the address again. It is confirmed to Mrs Cotton that on the information provided at that time that it is not considered that there is a real and immediate risk and that the police will not be attending. It is confirmed that the call will be subject to review by a supervisor as standard practice. All calls are assessed based upon the information supplied at the time of the call. All such calls received by Durham Constabulary are entered onto the Force Command and Control System (Smart Storm) and all incidents remain active until reviewed by a supervisor as only they can close

2 a call on the system. Durham Constabulary is committed to providing the best service possible to the public and in assessing whether any lessons can be learnt from this tragic incident. Deputy Chief Constable instructed Assistant Chief Constable , portfolio lead for public contact and response policing to undertake a review of the events prompting HM Coroner’s concerns. As a result, convened a working group to fully and properly consider the matter. Recommendations have been made to improve the system with the aim of strengthening the policy ensuring that the needs of the public are met. More details can be found below. Mrs Cotton has been spoken to and is being kept up to date during this review process so that she is aware that Durham Constabulary is taking this very seriously and are carrying out a full review aimed at improving the system where possible. The recommendations for improvements in the system have been discussed with the College of Policing who have confirmed that the improvements and system overall are in line with the National Toolkit for Right Care, Right Person. (2) During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises. Durham Constabulary Response At the time of the 16:44 call the matter had been assessed as not having an immediate need or risk to life or limb, it was considered to be a concern for welfare and as such Durham Constabulary would not have a power or right of entry.

3 The Coroner will be aware that the police have a right of entry under Section 17 of the Police and Criminal Evidence Act, but only in certain circumstances. The appropriate part of Section 17 is:- “ Entry for purpose of ….. (1) Subject to the following provisions of this section, and without prejudice to any other enactment, a constable may enter and search any premises for the purpose a) ………… (e) of saving life or limb or preventing serious damage to property.” The Courts have provided guidance in relation to the use of Section 17 and in particular in the case of Syed v DPP [2010] EWHC 81 (Admin), police officers explained to the court that they considered that a concern for welfare was sufficient to entitle the officers to enter the property through their power under
s.17(e) PACE. However, the High Court explained at [12] that, contrary to the officer’s understanding: “Concern for welfare is not sufficient to justify an entry within the terms of section 17(1)(e). It is altogether too low a test. I appreciate and have some sympathy with the problems that face police officers in a situation such as was faced by these officers. In a sense they are damned if they do and damned if they do not, because if in fact something serious had happened, or was about to happen, and they did not do anything about it because they took the view that they had no right of entry, no doubt there would have been a degree of ex post facto criticism. But it is important to bear in mind that Parliament set the threshold at the height indicated by section 17(1)(e) because it is a serious matter for a citizen to have his house entered against his will and by force by police officers. Parliament having set that level, it is important that it be met in any particular case.”

4 Many calls for welfare concerns that the police attend, and force entry result as ‘false alarms’ where the person is fit and well and not in crisis and this results in distress to them, even if well intentioned. The referral to contact the Mental Health Crisis Team would have been so that they could have made additional checks, and they may have been in possession of additional information that Durham Constabulary did not have. For example, Sophie may have been in touch with them for assistance and be receiving it. They could also make enquiries as to whether was in or had been in hospital that would have assisted. (3) During the 16:57 call there was no decision for police to attend, even though this was the third caller (and second professional caller) that had expressed serious concerns about the Deceased. Durham Constabulary Response During the call at 16:57 no decision was expressed to attend, however that matter was escalated as part of the Standard Protocol by the Control Room Supervisor to the Force Incident Manager who, based upon the cumulative effect of the calls made the decision for Policer Officers to be deployed to attend and effect entry to allow the appropriate services access to the premises. Police logs confirm this decision but unfortunately this decision to attend was not communicated to the caller or the family. It is recognised that this should have been communicated and is a point of learning. Measures have been put into place to seek to prevent such a recurrence of the failure to communicate. (4) Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time-sensitive.

5 Durham Constabulary Response The working group reviewed the position with regards to when a decision not to attend is given. It is clearly not possible to attend every call in relation to welfare concerns and in most cases the police are the wrong organisation to be involved in any event, nor would they have a power of entry. Often Durham Constabulary is asked to attend premises without the support of Mental Health Services also attending and even if officers have forced entry they have limited powers as to what they can do. A person cannot be forced to for example to attend hospital as legislation supports that a home is a place of safety which can only be interfered with in limited circumstances. Durham Constabulary recognises that there need to be safeguards within the system for speedy and timely reviews of decisions not to attend and 2 specific recommendations have been made to improve the current system. These recommendations have been approved and discussed with the College of Policing who have confirmed that they are line with the National Toolkit for Right Care, Right Person (RCRP) These recommendations will be implemented as soon as is practicable, with a target date of mid-July 2025 for full implementation. Good progress is already being made.. Once the recommendations have been introduced every decision not to attend will result in a review of police systems for further intelligence to support or amend the decision on attendance or otherwise under RCRP principles. These initial checks will be to review previous incident logs, checks on local and national police and partner systems. These checks will be done by a member of the control room staff and most likely by a dispatcher. In addition, if the decision under RCRP remained that no police would be attending then a review by the shift supervisor would be carried out. Such review would be a matter of routine and would be done as soon as reasonably practicable, as soon as is reasonably practicable, but in any event

6 expeditiously. The decision on whether to attend could change at any stage in this review process. Any change in decision would be communicated to the caller. On a second call about the same person within a 12 hour period where the answer on the first call was for the police not to attend there will be an immediate escalation to the Supervisor who will carry out a further review as soon as possible. If at this stage the decision remained that the police would not be attending there would be no reason to contact the called again as they will have been told that the police would not be attending by the Call Handler. If the decision changed so that the police would be attending, then the Supervisor will recontact the caller and update. Any additional calls within the 12 hours from the first call will be subject to the same review process as detailed above. Durham Constabulary is confident that the additional measures strengthen the policy and will meet the aims of serving the public.