Closely relatedConfidence 0.80 · moderateHow sure the judge model was that the two concerns are the same hazard, from 0 to 1. Links below 0.70 are never shown. High is 0.85 or more. A chain is only as strong as its weakest link, so the chain shows the lowest confidence of any of its links.2 reports · 2014–2019 One-page brief (print or PDF)
Greater Manchester Police received 2 coroners' reports about this hazard between 6 Jan 2014 and 23 Jul 2019.
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 13 specific actions.
“The access of Medacs Policies and Procedures to Medacs staff | was also concerned to hear that | was not aware of the Medacs Epilepsy Policy. He said in evidence that he had no specific recollection of the epilepsy policy, but he was aware that the Medacs policies were available in a 'loose leaf binder in most custody suites'. Asa very experienced FME J gave evidence that he had been asked to review most of the policies, but he could not specifically recall this one”
“| have an ongoing review of divisional policing entitled 'Transforming Divisional Policing' which looks at all aspects of improving the operational service we provide. | have specifically asked it to look at finding ways of processing detainees with greater efficiency in order to reduce their periods of detention,”
Closely relatedConfidence 0.80 · moderatea different coroner
“The Custody Sergeant did not open a custody record immediately on [the deceased] } Harris's arrival in the custody office. He used a piece of paper to record the”
Greater Manchester Police responded, stating 6 specific actions.Response (PDF) ↗
“With regard to the waiting time in the van dock - detainee cell space is allocated presently by a centralised GMP”
“An arresting officer may not be the same person as the transporting officer. The arresting officer will consider detainee risk to help determine the correct type of transport and whether handcuffs are required.”
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. Every quote shown was checked by code to appear word for word in the original report.
2014 → 2019Adam Harris5 years 6 months after Billy Paul Thomas Salton · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderate
Both reports highlight problems with how custody records are created and maintained, specifically regarding timely and accurate recording of detainee information.
Billy Paul Thomas Salton · 6 Jan 2014
“When the deceased is visited and checked all such visits should be | accurately recorded on the custody record”
“The Custody Sergeant did not open a custody record immediately on [the deceased] } Harris's arrival in the custody office. He used a piece of paper to record the”
“The access of Medacs Policies and Procedures to Medacs staff | was also concerned to hear that | was not aware of the Medacs Epilepsy Policy. He said in evidence that he had no specific recollection of the epilepsy policy, but he was aware that the Medacs policies were available in a 'loose leaf binder in most custody suites'. Asa very experienced FME J gave evidence that he had been asked to review most of the policies, but he could not specifically recall this one”
“| have an ongoing review of divisional policing entitled 'Transforming Divisional Policing' which looks at all aspects of improving the operational service we provide. | have specifically asked it to look at finding ways of processing detainees with greater efficiency in order to reduce their periods of detention,”
Stated action
“GMP has reviewed its arrangements for communication between custody and clinical staff to negate the practice of MEDACs staff working on two separate records of notes and to improve the continuity of care provided to detainees with health needs”
Stated action
“We already have a process that checks custody records to ensure visits are timely and carried out in accordance with the sergeant's risk assessment”
Stated action
“Since the death of Mr [name redacted], Custody Branch has significantly upgraded its ICIS computer system. This system prompts Custody Sergeants to undertake further reviews linked to specific/significant events affecting the detainees period of detention, including an exit risk assessment”
Stated action
“We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be a comprehensive review of each detainee. Rather, they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain key risk issues, for example medical conditions, medication required and so forth”
Stated action
“Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off”
“With regard to the waiting time in the van dock - detainee cell space is allocated presently by a centralised GMP”
Stated action
“An arresting officer may not be the same person as the transporting officer. The arresting officer will consider detainee risk to help determine the correct type of transport and whether handcuffs are required.”
Stated action
“the escorting officer is responsible for the safety, welfare, supervision and monitoring of a detainee. The role requires that a detainee is not left unsupervised in any Police vehicle.”
Stated action
“All detained persons arriving in the custody van dock area must remain under the direct control of at least one police officer; that requirement does not end until the detainee is accepted into the control of the custody staff.”
Stated action · timescale: August 2019
“From August 2019 the contents of the revised”
Stated action
“Greater Manchester Police are currently working with Greater Manchester Combined Authority and are exploring the introduction of a formal pre-detention medical assessment carried out by a Health Care Professional where a detainee remains in a Police vehicle in a van dock for a period in excess of 30 minutes”
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 Greater Manchester 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 TF-IDF compares shared words. Embedding compares meaning. Judge is the Nemotron Super verdict that decides whether a link is shown.
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.