Michael Thorley
7 Jul 2015 · Coroner John Pollard · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed entry to premises
“There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call.”
2. lack of policy on door entry
“There was no clearly thought-out and applied policy as to whether it was better to risk breaking down a door unnecessarily or whether to risk the life of someone who may be collapsed inside.”
3. missed methadone bottles
“When the officers searched the premises they failed to find approximately five empty methadone bottles which were in a kitchen cupboard.”
4. telephone location overlooked
“The telephone which was used to make the call was found (after the ambulance service re-called it), well away from the body. No explanation for this was forthcoming. This issue was not even considered as needing examination by the attending officers.”
5. third party involvement unconsidered
“None of the investigating officers considered that a third party may have made the phone call and then tidied up the flat and left, locking the door from the outside. When the officers gained entry there was no drug paraphernalia nor were there any opened prescribed medication packets. There was a large quantity of prescribed medication, none of which had been opened. There was no explanation as to why or how this situation may have arisen: This despite the fact that it was known that the deceased”
6. DI absent from scene
“The Detective Inspector did not attend the scene on the day as it was deemed not a Special Procedure Death and not one where he needed to attend. The representative of the Professional Standards Branch concurred with the view expressed by the Coroner that a D.I. should turn out to this type of death.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call.”
Later report
“The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased's residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.”
Responses
2015-0260-Response-by-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
Stated action
“The Specialist Operational Training Unit which is responsible for training officers in both decision making and tactics will use this example during their method of entry training modules.”