The publication last week of the Preventing Future Deaths report after the inquest for Mr Thomas Crabbe is the 27th PFD notice I’m aware of which mentions or relates to Right Care, Right Person. It comes after the conclusion of the 34th inquest I’m aware of where RCRP was a point of discussion or something raised in a response to a Coroner and which gives rise to questions about how the programme operates and what lies beneath or behind it.
I am still monitoring sixteen other deaths which are yet to reach inquest or inquiry conclusion which I suspect from what is currently known may be connected to the programme, but obviously that view may have to change once the evidence is fully heard in HM Coroners’ courts over the next year or two.
So far, the only public response of the police is the College of Policing’s “Briefing to Officers” which relates to proper preparation for RCRP-connected inquests – the only example I’m aware of where the police give policy-specific preparation advice for inquests. That mostly speaks for itself.
SIMILARITIES ACROSS PFDs
The PFD for Mr Crabbe (and responses to it) raises a number of questions when we start to join the dots with other PFDs, and I’m going to use the example of Lesley Higginson who died in Cheshire in 2025 and whose PFD was published only a few months ago. Greater Manchester and Cheshire police both work alongside North-West Ambulance Service (NWAS) and this is relevant to the point I want to make.
We know that NWAS issued a position statement on Right Care, Right Person to their five police forces in May 2024, after RCRP went live, and following some obvious problems in those early days. They reference this position statement in their response to the PFD for Mrs Higginson, an inquest in which, incidentally, they were not an interested party and did not attend or give evidence. Despite this, the Coroner issued them with a PFD, obliging them to respond within 56 days.
Their response states –
“The Concern for Welfare Response Criteria Guidelines Policy was introduced in May 2024, in response to the Right Care, Right Person (RCRP) National Partnership Agreement. NWAS have been clear and transparent with local system partners, including the Police, Acute Trusts, Mental Health Organisations and Councils regarding the deployment of ambulances when concern for welfare calls are made to the service and the circumstances in which an ambulance will and will not be deployed. NWAS and other system partners have previously noted that there is a gap in services for members of the public who may need concern for welfare call outs and this has been discussed in both strategic and tactical RCRP meetings, but not something that NWAS are able to fulfil unilaterally.”
What this actually means is: NWAS will not go to any call of any kind unless it is confirmed by someone the patient is present there and in need of medical care. They do not attend addresses where someone’s presence is merely assumed or speculated and we should remember for what follows, they have no right to force entry to buildings.
COMPARE AND CONTRAST
Both GMP and Cheshire were told this in 2024 by their ambulance colleagues and yet in Mrs Higginson’s case, when a private care company contacted 999 because they couldn’t raise her by telephone and a neighbour couldn’t see evidence that she was at home, the police bounced the call to NWAS who, quite predictably given their Concern for Welfare policy, above, declined to attend. The Coroner for Cheshire had to attempt to untangle all of that in the PFD and to some extent it should have been considered differently by the police. If her location is not known and there is a concern for her, it may be she’s missing or seriously ill / injured inside the property but unable to be seen.
Fast-forward to this year’s inquest for Mr Crabbe and we see GMP arguing a friend should contact the housing association or the ambulance service. Given the call to the police appears to have been out-of-hours, it meant the caller’s concern had to be delayed until the following morning because the ambulance service would have no legal power of entry, would refuse to attend because no-one could confirm Mr Crabbe was within the premises.
Sadly, the housing association found him deceased.
I’m pretty confident some of us reading the PFD for Mr Crabbe will point out he’d been deceased potentially for a few days, so a police response the evening before would likely also have found him dead but of course the point to be made in those kinds of cases is we don’t know people have been dead for a few days and that a faster response would have made no difference until you get there and see what you find.
PEDANTRY ISN’T POINTLESS
Whenever I hear it argued “we can’t know a better or faster response would have made a difference to the outcome” I deliberately and pedantically point out a different way to make exactly the same logical proposition is to point out “we can’t know a better or faster response would NOT have made a difference to the outcome”. These two sentences mean the same thing – it’s Shrödinger’s paradox in real life.
The main point here is we have collectively created conditions in which no emergency service will respond to a situation where someone could be at risk of death or serious injury, if the particulars are that we don’t know the person is in their home but it’s highly likely. The police may decline on that basis, the ambulance service may decline on that basis and it all highlights once more how assessments are made about what constitutes an “immediate risk to life” or an “immediate risk of serious harm”.
These are legal phrases and concepts, so they have a legal definition and I’ve covered this before if you want the full explanation, but the “immediacy” in these two phrases is not the immediacy of the death or harm, but the immediacy of the risk. There can be a risk that something will happen at any point from now on, without it being obvious that feared outcome is “happening now or about to”, which is the phrase erroneously employed in RCRP training and something which has had to be corrected by more than police force after an adverse inquest outcome.
LEARNING THE LESSONS
I have recently been supporting a family through an inquest where police decision-making was front and centre. Yet again, desperate circumstances and one in which the police should not have been placed, but in which they found themselves. The family said more than one that they just want to make sure “lessons are learned” so others don’t have to go through the same thing as they have.
Whilst remembering that Deborah Coles, Chief Executive of Inquest, once said to the police –
“You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons”
I feel we’re already starting to get there with RCRP specifically. Of the 27 PFD notices I’ve collated so far, around half of them relate to a failure to accept, understand or response to a stated risk which, for my money, seems to be one of those two “immediate risks”, of death or serious harm. We’re not going to reach a point where lessons are learned if organisations can’t talk to each other and if organisations don’t look beyond themselves for the wider lessons of RCRP.
In those 27 PFD, one police force has been the site of 7 deaths leading to a PFD, albeit the PFD has sometimes been sent to national policing or political targets, not the force themselves. 18 police forces have received an RCRP-PFD, six of them having received more than one. But it’s when you compare similarities across the police forces that you see the common problems.
I wonder whether the force who’ve had 7 have read them all to capture learning? – but more importantly, I wonder whether they’ve read the other 20 to think about whether those other force’s problems were things which could go wrong in their area? My £5 says they’re not – but I would love to stand corrected. The lack of public comment by policing on this subject is also part of the problem, because the responses to PFDs which are published a largely formulaic and performative – I fear cut / paste is being used.
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, 2026
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.
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