Source · IOPC Learning Case

Investigation into response to a concern for welfare - Greater Manchester Police, April 2021

Greater Manchester Police Ref: 2021/152017 Recommended 25 May 2022 Response due 20 Jul 2022

Welfare and vulnerable people

Case background

Text published by the IOPC.

On 20 April 2021, Greater Manchester Police (GMP) received a phone call from a person who was concerned for their friend, who had been in recent contact and was known to suffer from depression and anxiety. The call handler confirmed GMP would conduct a welfare check and call the ambulance service.

An incident log was opened and graded as a 'Grade 2' incident. Delays were encountered on the log and the escalation policy was not adhered to. The ambulance service called GMP to request assistance with forcing entry. Access to the property was gained and the female was found dead in the property, almost five hours after the initial 999 call.

During the investigation, we spoke with a number of witnesses, both police officer and ambulance staff, and reviewed radio transmissions, body-worn video footage, and the relevant call recordings. Investigators also reviewed local and national policies and training to see how these were implemented by those dealing with the incident.

During the investigation there was no indication any police officer may have behaved in a manner that would justify the bringing of disciplinary proceedings or committed a criminal offence.

Our investigation concluded in January 2022, but we waited for all proceedings to conclude before publishing our findings.

We concluded there was no indication any police officer may have behaved in a manner that would justify the bringing of disciplinary proceedings or committed a criminal offence.

We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system, and prevent a recurrence of similar incidents.

In this case, the investigation has identified organisational learning.

Recommendations and responses

4 indexed

Recommendation 1

Link to recommendation · Accepted

Addressed to: Greater Manchester Police

Linked bodies: Greater Manchester Police

IOPC recommendation

The IOPC recommends that Greater Manchester Police takes steps to ensure that the staff within the Force Control Centre understand the importance of the escalation policy and the individual responsibilities laid out within the policy for escalating incidents when they have been left unresourced for a period of time exceeding the targets for that grade. GMP could consider issuing communications to staff on these matters and/or ensuring that they are covered in appropriate training.

This recommendation follows an independent IOPC investigation concerning GMP's response to a concern for welfare report. The GMP call handler graded the incident as a grade two, requiring allocation within 20 minutes and response with an hour, and also contacted the North West Ambulance Service. When officers arrived at the address, the female was found deceased inside following death by suicide.

The IOPC investigation found that GMP took over four hours to arrive at the address, in spite of the incident being a grade two. As this was outside the targeted response time for grade two incidents, GMP’s escalation policy should have been implemented, which would have seen the log escalated to a supervisor for allocation. The IOPC investigation found that staff within the control room did not escalate the log as required, however, they did recognise that they should have escalated the log when interviewed by the IOPC. Given there were multiple missed escalation opportunities across multiple control room staff, steps should be taken to ensure that all staff within the control are aware of their responsibilities and that the policy is covered in training.

Response published by the IOPC

Recommendation accepted:

GMP revisited its Graded Response Policy (GRP) and made changes implementing a new GRP on the 1st February 2022. Incidents are now graded following a risk assessment via the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) framework and assessed on the information received as opposed to incident type or crime category. Incidents graded 1 are high risk incidents that require a response time within 15 minutes, incidents graded 2 are medium risk incidents that require a response time within 1 hour these are referred to as ‘go now’ incidents, incidents graded C are low risk incidents that can be responded to outside of 1 hour and are referred to as ‘go later’, C incidents are often dealt with by appointment at a time suitable to the victim in line with their needs. The new GRP incorporates escalation of grade 1 incidents to District Inspectors immediately following creation in the event that Dispatch staff are unable to task or allocate a resource; and escalation of grade 2 incidents to District Sergeants within 40 minutes in the event that Dispatch staff are unable to task or allocate a resource, the responsibility is then on the District Inspector / Sergeant to task a resource to respond to the incident to deliver a service to the public.

All staff within the Force Contact Centre (FCC) have received training on THRIVE and the new GRP incorporating escalation. At shift changeover times if an incident has not been resourced within the target time frame for arrival, staff within the FCC will re escalate to District Supervision.

Stringent measurement of attendance times are in place with daily data produced for both FCC and District colleagues. Any incidents within the grade 1 and 2 queues that are over 24 hours old are flagged to District Silver Commanders by the FCC Supervisor responsible for that District at the District morning pacesetter meetings, via email or Teams message if insufficient Supervisors are on duty within the FCC to have a dedicated Supervisor per District. These in the main are grade 2 incidents where efforts to speak with the caller / victim have failed due to their availability and there is deemed no threat to life to warrant forced entry under S.17 PACE.

District Silver Commanders are the Superintendents or Chief Inspector’s based on each District who have the responsibility for District resourcing that day. The FCC Supervisor will provide an update as follows:

Numbers of grade 1 and 2 incidents in the incident queue for the respective District Number of deployable patrols provided by the District to the FCC Number of incidents allocated Any incident the FCC wish to raise for example a high risk missing from home that has just been created Any incidents in the incident queue that are over 24 hours old (these should be very few and are frequently as referred to above)

Check the original case on the IOPC website

Recommendation 2

Link to recommendation · Accepted

Addressed to: Greater Manchester Police

Linked bodies: Greater Manchester Police

IOPC recommendation

The IOPC recommends that Greater Manchester Police incorporates, if possible, a system prompt on ControlWorks specifically for control room supervisors to alert supervisors when a log has been unresourced for a period of time that exceeds the target for the incidents grade.

The IOPC investigation found that GMP took over four hours to arrive at the address, in spite of the incident being a grade two. As this was outside the targeted response time for grade two incidents, GMP’s escalation policy should have been implemented, which would have seen the log escalated to a supervisor for allocation. The IOPC investigation found that staff within the control room did not escalate the log, despite being prompted to do so by the ControlWorks system. The IOPC understands that control room supervisors do not currently receive prompts like control room staff do. If supervisors were to receive the same action prompts on their screen as control staff, this would create a failsafe in case a log falling due for escalation was not escalated in a timely manner.

Response published by the IOPC

Recommendation accepted:

The FCC and CW (ControlWorks) team have now implemented an alert system for Grade 2 incidents to ensure we seek to resource within the 20 minutes. After 20 minutes the system will automate an orange tab alongside the Grade 2 incident to provide a visual prompt to the radio operator and supervisor that the log requires actioning. This is intentionally created 40 minutes prior to the 1 hour attendance time to allow sufficient time to review duty states of officers and where possible allocate a resource within 40 minutes.

Check the original case on the IOPC website

Recommendation 3

Link to recommendation · Accepted

Addressed to: Greater Manchester Police

Linked bodies: Greater Manchester Police

IOPC recommendation

The IOPC recommends that Greater Manchester Police takes steps to make method of entry equipment more readily available to officers when the need for method of entry (MOE) equipment arises. This could include assigning MOE tools to MOE trained officers at the beginning of their tour of duty.

The IOPC investigation found that when an MOE officer was requested after the initial officers arrived on scene and were unable to gain entry, the MOE officer did not have in their possession the necessary equipment to force entry. As a result, the officer had to travel to a police station to collect the kit before travelling onwards to the address. Whilst the IOPC were not able to quantify the delay this caused in the officer reaching the address, the investigation found this undoubtedly increased the officers response time, causing delays in officers and ambulance colleagues gaining entry to the property.

Response published by the IOPC

Recommendation accepted:

Each GMP District or Branch has a Method of Entry (MOE) SPOC (Single Point of Contact) who is responsible for the maintenance, storage and ordering of MOE kit and equipment. Most Districts have one central storage area of all MOE kit and some designated vehicles also have MOE equipment stored within them.

During the initial training course, students are informed of this procedure/SOP during the delivery of the twelve MOE safety rules. How this equipment is distributed is determined by the individual Districts or Branches so upon their return from training, they will be familiarised with each District or Branch process.

The SPOCs also have access to the GMP suppliers for ordering of new kit and equipment as and when it is required.

The recommendation to the SPOC network as a result of this tragic incident has been the need to audit their equipment and identify where there is insufficient equipment available for trained officers.

The Level 3 MOE training core syllabus covers the following:

Legal inputs including National Decision Model (NDM), Code of Ethics, Powers of Entry and Human Rights. Use of the ‘Lock Puller’. Use of the ‘Enforcer’ Use of levers

As of 1 April 2016, Level 3 MOE officers must complete a three hour refresher course every three years. There are 192 course spaces available per year for Districts and Branches to book their front line officers onto. How they decide who or how many need to attend is a matter for each District but skill spread across teams and reliefs, inclusion within Performance Development Reviews (PDRs) are all factors taken into consideration as long as the individuals meet the following criteria:

Job Related Fitness Test (JRFT) to level 5.4; A ‘safe to use’ lift and hold assessment; Up-to-date Personal Safety Training (PST).

Should there be an evidenced demand for additional courses, the training team would look for opportunities within the training plan to accommodate this.

Staff from within the Specialist Operational Training department meet quarterly with District Resource Management Units (DRMUs) and so understand the demand picture for training and ensure MOE training provision and availability remains part of this agenda.

The learning identified from this incident will form part of the initial MOE L3 training going forward with the package being updated for future delivery. This will also be reflected for new student officers joining GMP on the PEQF pathway who receive initial training on legislation and powers of entry.

It is also important that the key messages and learning from this tragic incident are conveyed to all other officers, particularly front line officers. In order to do this an article will be uploaded to the forces internal internet site and shared with the forces organisational learning team who publish a “Top 3” lessons message each month on which the learning from this incident will be conveyed. There has also been an updated Chief Constables Orders submission made for inclusion on the GMP Intranet to cover the MOE Levels, Training Opportunities and SOPs.

Check the original case on the IOPC website

Recommendation 4

Link to recommendation · Accepted

Addressed to: Greater Manchester Police

Linked bodies: Greater Manchester Police

IOPC recommendation

The IOPC recommends that Greater Manchester Police takes steps to improve their record keeping and archiving around when changes are made to the Call Handling Minimum Standards. This could be achieved by way of implementing a version control system on any changes to the standards, making sure to document the date of the change, who made the change, the reason for the change, and specifically what has changed compared to the previous version. In addition, previous versions should be appropriately archived and dated for when they were in effect from and to.

This recommendation follows an independent IOPC investigation concerning GMP's response to a concern for welfare report. During the investigation, the IOPC looked at how the call handler dealt with the call, and compared their actions to the Call Handling Minimum Standards. The IOPC understands these standards set out the way call handlers should handle calls regarding certain matters.

When the investigation requested documentary material showing the standards that were in place at the time of this incident, there were issues in establishing exactly what the standards were at the time of the incident due to updates that had happened since the incident. Insufficient records of when changes were made and what was changed meant it was difficult to understand what standards were in place at the time of the incident. Improving record keeping, particularly version control and archiving, would negate such challenges in the future.

Response published by the IOPC

Recommendation accepted:

The Force Contact Centre is in the process of implementing a new and improved system that will replace Sherlock. Sherlock, the current system, holds information on policy and procedure however there are limited options with this system in terms of version control, updates and organisation.

It is the FCC’s intention to replace the whole system with a new platform which is already used within other departments of GMP. Developers have been spoken to who have confirmed that these requirements can be built in and it is anticipated to have the new system in place by August 2022.

The project team are actively working on content which will take up to six weeks and the technical team are actively building the platform which will take around two weeks. The content will be migrated to the new system on weeks seven and eight. The system will then be tested on weeks nine and ten and training and implementation will be undertaken on weeks eleven and twelve.

A project management group consisting of subject matter experts (SME) from each area of Force Contact Centre has been set up who will review Sherlock content, archive outdated information and update policies and procedures as appropriate.

Once the content is up to date it will be built into the new system which comes with additional benefits including much improved version control, with changes time stamped and saved, usage analytics, which will help identify skills gaps and required training material and it will be far more responsive in terms of time taken to locate information.

The FCC are already familiar with the system as it is used for other tasks and so system navigation training should be simple to implement. Briefing notes and user guides will be developed and supervision will be given tutorials which they will then replicate with their teams.

Previously there has been limited investment in the FCC both in terms of resources and technology which has greatly affected its ability to meet demand. This approach resulted in underperformance and poor staff retention along with a number of IT challenges.

The newly agreed upon Force Contact Centre investment plan demonstrates GMPs commitment to improving service delivery. The FCC are in the process of recruiting in all areas of business to stabilise performance. Improving standards is an area of focus in addition to investing in equipment, software and process improvements that underpin FCC service delivery.

Check the original case on the IOPC website