His Majesty’s Coroner for Manchester North has last week issued a Preventing Future Death report to the College of Policing and the “RCRP Strategic Board” after the death of a woman by suicide in Manchester.
Katie Overd was a vulnerable woman in her 40s who was usually housebound as a wheelchair user. She had a number of health conditions and it was her practice to ring her mother each evening. On the 20th March 2025 her mother couldn’t raise her by telephone and they were concerned as they considered it impossible she would be out. They attended her address but could not gain entry and could not see inside because it was a second floor flat.
So they rang the police, at 2031hrs and the Coroner noted the call handler did not ask a question about whether the situation involved a risk to life. She was however in no doubt the situation described did involve such concern. Greater Manchester Police advised her to call North West Ambulance Service (NWAS) as the matter was deemed to be a medical issue by the police. At 2037, they re-dialled 999 for NWAS and had to fully repeat the story. As per their grading system, the ambulance service listed this incident as a “Cat 3” call which requires a 2hr response time (but that is often exceeded and on that evening was likely to be exceeded).
PRIVATE LOCKSMITH
Katie’s family therefore called an out of hours locksmith to enable them to gain entry to the property and found she was deceased at 2055hrs.
The Coroner wrote in the PDF –
“It was clear … their understanding and belief of what to do in such a crisis was to contact emergency services who would respond quickly. They were of the opinion they should ask for the police, due to both experience and a generally held public view …”
Ultimately whilst an ambulance would have been deployed it is clear for that any family would have to wait some hours. Once an ambulance arrived there would then have to be a request to deploy the fire service to gain entry.”
It concludes that there is no evidence to suggest that faster entry in this case would have saved Katie’s life, but in other cases, delayed entry may cost lives.
CONTEMPLATE THIS
Remember what a PFD document is – a legal document from a court, flagging up that unless certain action is taken, lives may be lost.
Now read the Coroner’s “Matter of Concern” –
“There has been a decision made not to undertake any proactive public communications in relation to the implementation of Right Care Right Person. The court heard evidence this was both on a national and regional basis. As a result, the public who have significant concerns for the life of their family members may not seek assistance as quickly as they could do, labouring under the misapprehension that there will be a timely response from emergency services.”
WOW!
A coroner is saying, “The public who have significant concerns for the life of their family [are] … labouring under the misapprehension there will be a timely response from emergency services.”
WOW!
I admit to reading this one with some frustration the Coroner didn’t flag some other matters of concern for GMP specifically and send the notice to them as well. It is only directed at the College of Policing and the “RCRP Strategic Board”, but I had to wonder about the call handler not asking basic questions, which is something we’ve seen in other RCRP inquests. I had to worry about the risk to life situation therefore not being identified and treated as such, which is also something we have seen in other RCRP inquests.
RCRP Disclaimer –
- I’m not sorry to be raising this again – people are losing their lives and others are at risk.
- There have been 20 completed inquests
- 17 preventing future death reports (of relevance to different aspects)
- 12 other deaths I’m aware of which are yet to reach inquest where I suspect RCRP will be thought relevant.
- The police service decided to ignore warnings I made about exactly this before anything like as many deaths had occurred.
- It ignored enquiries from journalists about deliberately ignoring warnings.
- If no-one will talk about this, all I’ve got left is to keep chipping away at highlighting problems which I saw coming years ago, when I first learned what they were going to do.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
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All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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