Lisa Taylor-Penny died in 2025 after self-injury and the inquest into her death concluded in Cheshire with a very sad narrative verdict just a few months ago.
Yesterday, His Majesty’s Coroner published a new Preventing Future Deaths (PFD) report after concerns were caused arising from the application of the Right Care, Right Person programme. This becomes the 26th completed inquest of which I am aware, and the 22nd PFD notice which has bearing on the program – and I am still attempting to identify two further inquests referred to in publications by the Independent Office for Police Conduct which I am satisfied are none of the 26 found so far.
The Coroner in Cheshire used a particularly striking turn of phrase to sum up what she thinks the problem was and I think it neatly sums up some of the issues we have seen in other RCRP cases –
TRAMLINES, NOT GUIDELINES
Ms Taylor-Penny was found at her home address in July 2025 having last been seen alive the day before. Concerns had been raised earlier that day, from 1:30pm by carers and social workers from the local authority who had attended her house for hours during which they repeatedly and persistently called the emergency services to try and obtain access. After nearly seven hours trying to obtain assistance, a police officer took an “appropriate operational decision” to enter and Ms Taylor-Penny was found deceased.
She had a long standing history of mental health problems, her daughter having died by suicide in September 2024 and this was associated with a further deterioration in her own wellbeing. She had spoken about feeling suicidal but denied plans or intent to do so. When she was found, there were a large number of empty blister packs next to her from a variety of medications and an undated note consistent with intent to take her life was left prominently on the kitchen side and she had very recently updated her will. However, no probable mechanism of death was been established.
The coroner stated her “matter of concern” was –
“Right care right person” (RCRP) is being implemented in a very rigid manner suggesting that call handlers may be using it as “tramlines not guidelines”. I am concerned that it does not leave sufficient scope for call handlers to escalate calls for a senior member of staff to consider exercising professional judgment. In particular, where other professionals who are familiar with RCRP are nevertheless indicating a professional view that they need police attendance to secure entry and are expressing a concern for life and limb.”
OTHER CASES OF CONCERN
This characterisation rings true to me – tramlines, not guidelines. We saw just a few weeks ago, the publication of the first stage of the Southport Inquiry where the chair devoted a short section of the report to the refusal of Lancashire Police to assist education services with a ‘welfare check’ on the offender. He stressed that call handler had reached the right conclusion as per the policy itself, but emphasised that this lacked a professional curiosity and the necessary flexibility to recognise there was an important role for the police. You have to read between the lines of the report, but I submit to you that it’s there, as clear as day.
We also have hints within some of these cases about the blurred line between welfare checks and “missing” – some reports about vulnerable people are predicated not just upon concerns for them, but also on it not being known where they are or where they’ve gone. We can think about other situations where people died at home, like Sophie Cotton in Durham where the police declined to respond to requests from other agencies, only to admit later they were wrong to do so.
I’ve worried a lot over the last two decades about flowcharts – they are used a lot in policing for things like this. They perhaps sit at the heart of the “tramlines, not guidelines” dilemma. You come up with a bright idea about how to make the world a better place and to aid decision making by control rooms or front line officers, you make that policy diagramatic – a flowchart which contains a decision tree, taking you to different outcomes depending on how you answer the questions, all of it compounded by what I still insist is a confusion about the legal term “immediate risk to life“.
I long since refused to create them for policing & mental health, including after being asked to do so to “make things easier”. You can see what I preferred to do instead, in the Quick Guide series on this website.
FLOWCHARTS
The problem with them – and RCRP has flowcharts for control rooms – is they are rarely able to reflect the number of variables and the complexity and ambiguity of real world situations. If they simply – or over-simplify things – then you risk a flowchart which takes you to the wrong conclusion; if you don’t, you end up with something so complicated it makes the London Underground map look like a a couple of intersecting straight lines.
The RCRP flowcharts I saw in my service were in the former category – over-simplifying complicated things and which definitely get you to the wrong answer some of the time. Things like “refer to the crisis team” for people where the flowchart hasn’t asked you if the person is already in receipt of care from a mental health trust. Many “crisis teams” run by trusts are specifically for out-of-hours, unscheduled care for people already receiving the trust’s services, they are not necessarily for anyone experiencing what the police think is a mental health crisis. And the big one is “call an ambulance” for someone who doesn’t need an ambulance at all, but is in need of something that either doesn’t exist or which isn’t available to them at the point in time.
But of course, once you publish your flowchart, train it to staff in a short (online?) training session, it achieves an organisational status as policy and call handlers will often quite fairly assume the policy author and flowchart artist has considered ALL of the relevant variables and complexities to draw the flowchart correctly, to get people to the right conclusion and some will believe the flowchart is reliable. We have to wonder whether these tools genuinely discourage thought, which is never a good thing, in my view.
And that’s where things go awry – tramlines, not guidelines.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2026
I am not a police officer.
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