Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Gaia Pope-Sutherland · 21 Jul 2022 · Rachael Griffin, Dorset
“some parts of these policies remain ambiguous or confusing. For example, in the Call Handling, Grading and Deployment Policy, there is no specific paragraph that explains that the Force Incident Manager should be notified of a high risk missing person”
judiciary.uk/…/gaia-pope-sutherland-prevention-of-future-deaths…
What was promised
Stated action 1 · response to Gaia Pope-Sutherland (21 Jul 2022) · stated timescale: 15 September 2022
“We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good”
judiciary.uk/…/2022-0222-Response-from-College-of-Policing.pdf
Stated action 2 · response to Elaine Tarbuck (7 Jul 2025) · stated timescale: none stated
“NWAS, in partnership with Greater Manchester Police (GMP), has identified a recurring thematic issue involving calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare as outlined in the Right Care, Right Person stakeholder meetings. These concerns have been formally escalated to Senior Leaders within GMP and to the Deputy Mayor for further consideration and action.”
judiciary.uk/…/2025-0342-Response-from-North-West-Ambulance-Ser…
Stated action 3 · response to Elaine Tarbuck (7 Jul 2025) · stated timescale: none stated
“The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear.”
judiciary.uk/…/2025-0342-Response-from-College-of-Policing.pdf
What recurred
- 7 Jul 2025 · Elaine Tarbuck · Timothy Brennand
- 19 May 2026 · Catherine Morgan · Patricia Harding · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Elaine Tarbuck · 7 Jul 2025
“The emergency response had come about because of a new 'Right Care, Right Person' policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased's residence.”
Later · Catherine Morgan · 19 May 2026
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
What happened next
Evidence found · stated action 3
“New toolkit supports policing to respond effectively to mental health incidents in partnership with other agencies.”
Right Care Right Person (RCRP) national guidance ... · college.police.uk/article/rcrp-national-guidance-launched
“Right Care Right Person (RCRP) aims to ensure vulnerable people get the right support from the right emergency services.”
Right Care Right Person toolkit · college.police.uk/guidance/right-care-right-person-toolkit
“While RCRP provides clearer guidance on when police should and should not be involved, its implementation is shaped by resource constraints, gaps in inter”
Should police be turning up at all? managing mental health ... · tandfonline.com/doi/full/10.1080/10439463.2026.2659187