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recurance

Kesia Leatherbarrow

16 Apr 2015 · Coroner Joanne Kearsley · Manchester (South)

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. 17 year olds denied accommodation when refused bail

    “recent changes to legislation means that whilst in custody 17 year olds are now treated as children for the purposes of the Police and Criminal Evidence Act (PACE). However the failure to make legislative changes to the supporting legislation means that for 17 year olds there is an anomaly in the system particularly around the provision of accommodation for a 17 year old who is refused bail”
  2. 2. lack of accommodation for children under 17

    “across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available”
  3. 3. absence of exit risk assessments for self-harm cases

    “Greater Manchester Police have implemented a system to try and ensure that this situation does not happen again. It was therefore decided to hold a joint medical and police exit risk assessment when someone who has displayed self- harm ideation or behaviour leaves custody”
  4. 4. communication breakdown between youth offending teams

    “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation”
  5. 5. failure to record safeguarding intelligence

    “No intelligence was placed on [the deceased]'s nominal profile despite a number of concerning contacts with her by officers”
  6. 6. lack of safeguarding protocol for non-criminal concerns

    “The Inquest heard a great deal of evidence from officers as to their understanding and actions. No intelligence was placed on [the deceased]'s nominal profile despite a number of concerning contacts with her by officers. It is a core function of the police to submit such intelligence”

Linked reports

Repeats an earlier warningBilly Paul Thomas Salton6 Jan 2014 · 1 year 3 months earlier
Closely relatedConfidence 0.85 · high

Earlier report

“Risk assessments carried out whilst in police custody should be recorded when they are done.”
Original on judiciary.uk ↗

This report

“It was therefore decided to hold a joint medical and police exit risk assessment when someone who has displayed self- harm ideation or behaviour leaves custody”
Full chain: Delayed risk assessment documentation and missing exit assessments for self-harm

Responses

2015-0143-Response-by-CPS.pdf ↗· MEDACS Healthcare

Stated action

“The CPS Operations Directorate has also been considering the national implications and as a result ensured we have modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare”

2015-0143-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care

2015-0143-Response-by-Home-Office.pdf ↗· Home Office

Stated action · 12 February 2015

“Following a review of the provisions concerning the treatment of 17 year olds under the Police and Criminal Evidence Act 1984, the Government has committed to changing the law to ensure that 17 year olds are treated in the same way as 10 to 16 year olds as soon as a legislative opportunity arises. In November 2014 we were able to work closely with the Ministry of Justice to use the Third Reading of the Criminal Justice and Courts Bill to make a partial change to the current provisions in PACE,”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error