Missing person risk assessment not provided
West Midlands Police received 2 coroners' reports about this hazard between 11 Jan 2023 and 3 Jun 2024.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing.”
Original on judiciary.uk ↗ West Midlands Police responded, stating 1 specific action.Response (PDF) ↗
“WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol”
- 1 year 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“I am not reassured BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy.”
Original on judiciary.uk ↗ Repeated from the earlier report:missingperson
West Midlands Police responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The policy describes the actions to be taken when a patient is missing or AWOL”
Stated timescale: July 2024
“The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out 'why the risk is considered to be present'. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”
Stated timescale: 26 July 2024
2 more stated actions in the Promises tab.
- All reports to West Midlands Police
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2024Tcherno Bari1 year 5 months after Leroy Hamilton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight shortcomings in West Midlands Police's handling of missing‑person cases, specifically around risk assessment and information sharing.
Leroy Hamilton · 11 Jan 2023
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing.”
Original on judiciary.uk ↗ Tcherno Bari · 3 Jun 2024
“I am not reassured BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol”
Stated action
“WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol”
Stated action · timescale: July 2024
“The policy describes the actions to be taken when a patient is missing or AWOL”
Stated action · timescale: 26 July 2024
“The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out 'why the risk is considered to be present'. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”
No specific action could be extracted with a verified quote.
Stated action
“I will respond on these points in particular”
Stated action · timescale: April 2024
“the APCC has developed guidance for members on the Right Care, Right Person approach. The guidance, which was launched in April 2024, strongly encourages PCC oversight of the planning and delivery of the Right Care, Right Person approach to ensure vulnerable people receive the right support from the right services.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to West Midlands Police at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2024 | 0.76 | 0.11 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.