Grant Lowry

[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 THIS RESPONSE IS BEING SENT TO: Clare Bailey, HM Senior Coroner for the coroner area of Teesside & Hartlepool in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ dated 30 March 2026 following an inquest into the death of Grant Nicholas LOWRY that concluded on 26 March 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, the Chief Constable of Cleveland Police provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 21st MAY 2026 CORONER’S MATTERS OF CONCERN & DETAILS OF ACTION TAKEN HM Coroner’s Regulation 28 Notice the Coroner identified the following matters of concern (brief summary): During the inquest into Grant Lowry’s death in June 2022, issues with communication and record keeping relating to searches for Grant were identified. The issues impacted on the quality and effectiveness of the searches undertaken to locate Grant Lowry. These issues also impacted police tasking of further and full searches of heat sources identified by the National Police Air Service (NPAS) helicopter. The specific issues (in bold), and the force’s response, are set out below:
1. The location of the first NPAS heat source was not recorded accurately.
3. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the police call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around Summerhill Park had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.

[Page 2] Actions taken to address these concerns are as follows: The feedback and organisational learning set out in the statement provided by Greater Manchester Police (GMP) has been shared with staff via the force’s Specialist Training Tactical Governance Group. This group is responsible for ensuring that specialist training is identified and delivered through the force’s mandatory or annual training schedule, and that appropriate training is delivered to support operational requirements. The learning from GMP’s feedback has also been provided to the force lead for the Search portfolio, and includes prioritisation of the requirement to record:
• clear and comprehensive rationale for operational decisions, and
• the necessity of ensuring that any critical search areas which cannot be thoroughly examined are explicitly documented and flagged for follow-up during daylight hours. In November 2024, the force introduced a First Line Leadership Development Programme for all operational Sergeants and staff equivalents. This input consisted of a week-long course and included development on how to manage incidents as an ‘Operational Bronze’ commander, outlining their supervisory responsibilities in accordance with College of Policing Authorised Professional Practice (APP). Recording of decision-making and supporting rationale was included as part of this input. A large cohort of operational bronzes have now been trained. Future continuous professional development (CPD) sessions for front line supervisors will include learning identified from this incident. New Sergeants and Inspectors training will be delivered by the end of 2026. A wider review of the incident is scheduled to take place in June 2026 to identify any staff development needs. Direct one-to-one reflective learning will be done with those staff identified as requiring additional training or development as a result of this inquiry. Since the incident, the force has made changes to how it supervises, handles and prepares officers for missing persons investigations:
• In January 2023 the force amended its structure to a Basic Command Unit (BCU) model. The BCU model is led by a Chief Superintendent, and consolidates resources, personnel, and emergency response across multiple neighbourhoods or boroughs to manage demand, improve flexibility, and deliver consistent policing. This change aligned the force to the same operating model as the Local Authorities, and established four Local Policing Areas (LPA) of Hartlepool, Stockton, Middlesbrough and Redcar & Cleveland each led by a District Commander (Superintendent). One of the main benefits of adopting this model was increasing the provision of a Response Inspector across all four districts, instead of one Inspector for South (Redcar and Middlesbrough), and one Inspector for North (Hartlepool and Stockton). This ensures each LPA has a Response Inspector available to manage the initial response to critical incidents (such as high-risk ‘Missing From Home’ incidents) in line with relevant frameworks, ensuring appropriate resource and partner- agency deployment and effective risk management takes place operating in line with the role and responsibilities of a Response inspector | College of Policing.
• In 2024, enhancements were made to the force digital records management system (referred to as Niche), which now enables real-time monitoring of all live ‘Missing From Home’ cases via a dedicated

[Page 3] dashboard. The dashboard is accessible to Duty Inspectors and Silver commanders (24/7). As a result of this change, operational actions are more effectively tracked and handovers have improved.
• In October 2024, the Force introduced a dedicated Missing Persons Investigation Team consisting of a Sergeant and 6 officers to review live and long-term missing from home reports during office hours 7 days a week. This supplements the work of Response Inspectors 24/7 in this area.
• Specific Missing Persons training was rolled out late in October/early November 2024. This training was delivered to all control room teams, including call handlers, dispatchers and operational supervisors (Sergeants and Inspectors). There has been improved staff development by introducing regular staff training and briefing sessions. These sessions are in addition to scheduled CPD training days.
• In March 2025 the Force Control Room undertook a review of the Missing Persons question set, assessing it against the Authorised Professional Practice for Missing Persons. Additional supervision has also been increased with explicit scrutiny of high- risk missing persons investigations by senior officers (Silver Commanders):
• In December 2024, the force amended its Silver Commander rota to provide visible and supportive leadership beyond office hours and into periods of heightened demand. Under the revised arrangements, Silver Commanders now operate on a shift-based system, with the late-shift Silver Commander serving from 1700 to 0300 hours and remaining on-call until 7 am. This ensures a physical supervisory presence during busier evening periods, enabling Silver Commanders to assume tactical control of incidents in support of response supervisors and operational teams, and, where appropriate, to liaise with LPA Inspectors, partner agencies and other stakeholders to develop initial and dynamic working strategies.
• The role of the Silver Commander in ‘Missing From Home’ investigations is to oversee the Duty Inspector’s tactical plan. The Silver Commander will also manage resourcing requirements to meet their strategic objectives.
• Where appropriate, the Silver Commander will liaise with local policing Inspectors, partner agencies and other stakeholders to develop initial and dynamic working strategies to support investigations. Silver Commanders are usually of the rank of Superintendent, and they provide oversight of all High Risk ‘Missing From Home’ incidents in the force.
• Further oversight is provided by Pacesetter meetings which take place twice a day, one in the morning (chaired by Gold (Chief Superintendent or Chief Officer)) and one in the evening (chaired by the Silver Commander or Force Incident Manager from the Force Control Room) where missing persons are a standing agenda item.
• To further strengthen capability and ensure consistency of approach, later in 2026 the cadre of Silver Commanders will receive annual CPD designed to enhance their knowledge, operational effectiveness and decision-making proficiency. The learning identified from this incident will be included as part of this.
7. There were delays in requesting PolSA Mutual Aid from neighbouring police forces.

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8. There were delays in requesting the involvement of Mountain Rescue (with their dogs) and the police dog unit. Actions taken to address this concern is as follows: The force has significantly improved the operating procedures and governance around its Specialist Capabilities areas, including police dogs, to ensure sufficient resilience is maintained. In addition, the geographical distribution of Licenced Search Officers (LSOs) has been reviewed as part of the Specialist Capabilities Strategic Threat and Risk Assessment (STRA). Consequently, minimum staffing levels will be increased and more evenly aligned across the force area. Promotion of the PolSA role was undertaken in 2022 and 2023 to raise awareness among operational frontline Inspectors and Sergeants. PolSAs often provide advice remotely particularly in the early stages of an incident. Although specialist resources can be co-ordinated and scaled as an incident develops, the organisation is not always in a position, particularly during the earliest stages of a response, to immediately deploy fully constituted specialist teams or specialist capabilities. The PolSA course undertaken by PolSAs highlights the resources that may be utilised during a search such as National Police Air Service (NPAS) and Mountain Rescue Teams (MRT). In addition, MRT recently provided input into Licenced Search Officers’ professional development, with the aim of raising awareness of the benefits they can bring to searches. A rota lead for PolSAs has been introduced. The lead reports into monthly rota governance chaired by a Superintendent. The chair reports strategic rota assurance into an Assistant Chief Constable at the Specialist Capabilities Board. Having this increased scrutiny over all rotas, including each rota area having a dedicated lead officer, provides the force with confidence that the rotas are sufficiently resilient and can respond 24/7 when required. Since this governance has been introduced the PolSA rota has been managed more effectively, with no reported adverse occurrences linked to resilience. Whilst the force has ensured that it undertakes all National Police Air Service (NPAS) allocated flying hours and maintains appropriate level of use of NPAS search capabilities, it has furthered its aviation capability for searches. Whilst NPAS remains a viable tactical option for supporting missing person searches, the force has significantly enhanced its drone capability since 2023. Cleveland Police now has 58 accredited drone pilots and an operational fleet of 15 drones, providing a resilient and flexible asset. This capability is available at all times and is routinely employed in support of High Risk ‘Missing From Home’ investigations. The drones are equipped with advanced tracking functions and high-grade night imaging technology, enabling effective searching across challenging environments and in conditions where visibility is otherwise limited. In addition to conventional deployment, the force has introduced a fleet of drones through the Drone as First Responder (DFR) programme. Cleveland Police is the first northern force to adopt this pioneering capability, and one of only five forces nationally who have this capability. This capability enables a drone to be launched remotely by trained operators, within a defined geographical area, allowing the drone to arrive at the scene of an incident within 60 seconds of a report being received by the Force Control Room. This rapid

[Page 5] deployment provides early situational awareness, supports initial threat and risk assessment, and allows for the swift identification of search areas, hazards, or persons of interest before ground units arrive. The drone capability significantly enhances the effectiveness and efficiency of the early response phase, particularly in time critical missing person investigations. There are wider plans to extend this capability in future. Issues with officer equipment During the inquest it was identified that the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.
4. Cleveland Police continue to extend our deepest sympathy to Grant’s family and friends and apologise for the failings identified.
5. DETAILS OF FURTHER ACTION PROPOSED As per section 3, The following are actions which still require implementing by the force: Future Continuous Professional Development Future CPD sessions for front line supervisors will include learning identified from this incident. New Sergeants and Inspectors training will be delivered by the end of 2026. A wider review of the incident is scheduled to take place in June 2026 to identify any staff development needs. Direct one-to-one reflective learning will be done with those staff identified as requiring additional training or development as a result of this inquiry. To further strengthen capability and ensure consistency of approach, later in 2026 the cadre of Silver Commanders will receive annual CPD designed to enhance their knowledge, operational effectiveness and decision-making proficiency. The learning identified from this incident will be included as part of this. Officer Equipment This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both

[Page 6] Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.
6. SIGNATURE Chief Constable Cleveland Police

Dear Madam

I write following conclusion of the Inquest touching the death of Grant Lowry. Following the Inquest, you asked the Trust to confirm "that staff are reminded to undertake a risk assessment when undertaking medication reviews". To provide further assurance regarding risk assessment processes following clinical reviews, it is important to note that risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment. During patient consultations, it is expected that risks are reviewed in accordance with the individual's presentation, mood, and sleep patterns, and that direct questions are posed in relation to self-harm and suicidal ideation. In addition to risks to self, whether intentional or unintentional, clinicians are required to review risks from others, risks to others, forensic risks, risks arising from the service itself (including iatrogenic harm), safeguarding concerns, and risks relating to physical health, among any other relevant risk factors. Community Modern Matron Stockton & Hartlepool AMH Planned Care Marton Road, Middlesborough Cleaveland TS4 3AF

In Grant's case a call was made to Grant's mother by a trainee nursing associate, has previously agreed, to discuss Grant's medication. Where contact is made with carers, their views are sought in accordance with the domains set out within the safety summary (risk assessment). In circumstances where information is being obtained from carers, it is expected that a general discussion is undertaken regarding any changes in presentation that may have an impact upon the individual's risks. Following the Inquest this matter has been escalated through the Quality Standards Group, which is chaired by the Associate Directors of Nursing and attended by Team Managers, Matrons, and Clinical Specialists. A formal discussion was held at the Quality Standards meeting on 8th April 2026 to address this information, with a request that the findings be cascaded to clinical teams accordingly. I can confirm that, following GL's death, changes have been made to the electronic care recording system currently in place. The system now incorporates an automatic prompt requiring clinicians to confirm whether a risk assessment has been reviewed when completing a clinical entry; where it has not, a documented rationale must be provided. The electronic system is configured such that a clinician is unable to save a clinical entry without either confirming that an individual's risks have been reviewed or providing an explanation as to why this was not possible. Where risks have not been reviewed directly with the patient, for example in circumstances where contact was made solely with a carer, this would be recorded as the rationale upon saving the clinical entry. I hope you are assured that learning arising from the Inquest has been acted upon and discuss with clinical teams. We reiterate our sincere condolences to Grant's family.