Karen Burns

Dear Sirs,

Re: Regulation 28 report, prevention of future death pertaining to Ms Karen Burns (deceased)

Firstly on behalf of West Midlands Police may I extend our most sincere condolences to the family of Ms Burns following her sad death.

Pursuant to Regulation 29 of the Coroners (Investigation) Regulations 2013 this is the response of the Chief Constable for West Midlands Police to the Coroner’s Regulation 28 report to prevent future deaths dated 12 August 2019. The Coroner’s report and this response arise from the inquest into the death of Karen Jane Burns which was concluded on 12 August 2019.

1. The coroner raises two matters for consideration. First, the 101 call made by the deceased’s ex-partner was incorrectly graded as a P3 (response time of 8 hours) and not a P2 (response time of 1 hour).

2. West Midlands Police accepts the call was incorrectly graded. This was a human error. It has been addressed with the staff in question through management action. Further

Keeping our Communities Safe and Reassured

Preventing crime, protecting the public and helping those in need STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES

Director of Legal Services )

Your Ref:

Our Ref: L14002652/JS

Email: jointlegalservices@west-midlands.pnn.police.uk

Date: 8 October, 2019

Area Coroner, Birmingham and Solihull Coroner’s Court 50 Newton Street Birmingham B4 6NE

By email: birmingham.coroner@nhs.net

JS / L14002652 / 00206769 Page 2

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.

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.

4. Within the limits of the resources available to it, it is the aim of West Midlands Police to allocate these in the most efficient and appropriate way to deal with the demand for a huge range of policing activities. West Midlands Police recognises that response to emergency calls from the public within an appropriate time is of vital importance and seeks to ensure appropriate prioritisation based on threat, harm and risk.

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:

a. Instituting a process of escalation, whereby dispatchers can escalate calls about which they have particular concerns to a supervisor so resources can be prioritised for that call when possible.

b. Instituting a process of involving the Force Incident Manager when response shifts become particularly busy so resources from outside the area can be redeployed to response, where possible. (This process was employed on the night of 22/23 March 2019 and further units were allocated to assist in Birmingham East. These additional units were immediately deployed to P1 incidents requiring assistance and therefore were unavailable for allocation to any P2 incidents.)

c. Instituting a “Log Closure Doctrine” to encourage bolder decision-making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls with the most pressing needs.

JS / L14002652 / 00206769 Page 3

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.

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

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

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 despatch, allowing for improved identification of resource availability and response times.

Monitoring of call response times and resolution has demonstrated that our actions taken a) to e) have improved our ability to respond with the finite resources available.

Dear I x RE: Police and Crime Commissioner's response to the Coroner's Regulation 28 report: Ms Karen Burns (deceased) would like to express my deepest sympathy to the family of Ms Burns following her sad death sincerely apologise for the delay in response to this report Please see below response from the West Midlands Police and Crime Commissioner to the Coroner's' Regulation 28 report to prevent future deaths dated 12 August 2019. The response has arisen following the inquest into the death of Karen Janes Burns, which was concluded on 12 August 2019. The coroner's report notes two matters for consideration: The 101 call made by the deceased's ex-partner was incorrectly graded as P3 (response time of 8 hours) and not a P2 (response time of hour): Since 2010, we have lost 2,131 officers and {175 million in resources. This has meant we have had to prioritise certain aspects of the service and have less ability to cover everything as we have done in the past: 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: Additional training for all control room staff will take place to ensure such errors are eliminated as far as possible. The Coroner's report found 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. 2 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. Lloyd House, Colmore Circus Queensway; Birmingham, B4 6NQ 0121 626 6060 WWW . westmidlands-pccgov.uk @WestMidsPCC

With the limited resources available, West Midlands Police aim to allocate these calls in the most efficient and appropriate way to deal with the demand for a huge range of policing activities. It is clear that over the last few years, the West Midlands policing mission has grown. One of the ways in which it has grown is through the Police helping other services to deal with increased mental health demand_ West Midlands Police recognise that response to emergency calls from the public within an appropriate time is of vital importance and they seek to ensure appropriate prioritisation based on threat;, harm and risk Before and after the events of Ms Burns' death, West Midlands Police has taken dramatic steps to ensure that the response resources it has, are allocated as quickly and efficiently as possible to all emergency calls. These include:
a. Introducing a process of escalation, where dispatchers can escalate calls which have particular concerns about;' to supervisor_ This means resources can be prioritised for that call when possible.
b. Introducing process of involving the Force Incident Manager. When response shifts become particularly 'resources from outside the area can be redeployed to response, where possible (This process was employed on the night of 22/23 March 2019 and further units were allocated to assist in Birmingham East: These additional units were immediately deployed to P1 incidents requiring assistance and therefore were unavailable for allocation to any P2 incidents ) Introducing a "Log Closure Doctrine"_ This will encourage bolder decision- making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls with the most pressing needs: 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 Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60_ Changing the dispatch model;, including where people sit and how interact; to promote more efficient handling of calls: Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts: West Midlands Police takes its response to emergency calls extremely seriously. The force constantly monitor the level of resources and performance to ensure appropriate resources are allocated across the full range of demands which the police face Learning from this incident has been captured and training has been provided to the call handlers involved; new Command and Control platform is also being developed to support the call handlers and those involved in resource despatch, allowing for improved identification of resource availability and response times. This has also triggered a review of THRIVE+ training for staff Lloyd House, Colmore Circus Queensway, Birmingham; B4 6NQ 0121 626 6060 WWW westmidlands-pcc govuk @WestMidsPCC very they busy logs_ they

Monitoring of call response times and resolution has demonstrated that West Midlands Police's actions taken have improved ability to respond with the limited resources available to them: 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: Once again, apologise for the lateness of this response and thank you for your patience.