Dear Mr Sowersby, Regulation 28 report: Amy Anne Levy Thank you for your Regulation 28 Report dated 6 June 2025 concerning the tragic death of Amy Anne Levy. We acknowledge the serious concerns raised regarding the absence of guidance on leaving voicemail messages in time-critical situations and the potential implications for public safety. We understand that your primary concern relates to the lack of clear guidance, training, or policy for police officers and support staff on when to leave voicemail messages, particularly in urgent circumstances where critical information is required to prevent harm or loss of life. The College of Policing is committed to supporting operational excellence and public safety across all forces. In response to your report, we have taken the following actions and commitments: o We have liaised with Surrey Police and Avon and Somerset Police to understand the chronology of events and their subsequent actions. Surrey Police have updated their deployment procedures and developed training on voicemail protocols, scheduled for implementation from September 2025. o Avon and Somerset Police have revised their handling codes for incidents involving suicidal individuals and will issue guidance through their Professional Standards Department on appropriate voicemail practices. o The College will actively support and facilitate the sharing of these practices nationally. This will be coordinated through the relevant National Police Chiefs’ Council (NPCC) Working Groups to ensure consistent adoption across all forces. o We are currently updating the national Contact Management Curriculum. This curriculum ensures uniform training standards for contact management staff across all forces. The

revised curriculum will explicitly address the issue of voicemail guidance in emergency contexts and will incorporate the lessons learned from this case. o The updated curriculum is undergoing a comprehensive quality assurance process and is scheduled for national rollout by March 2026. All forces will be expected to align their training programs with this revised framework. We are committed to ensuring that the learning from this case leads to meaningful and lasting improvements in policing practice. We extend our sincere condolences to Amy’s family and thank you for bringing this matter to our attention. Please do not hesitate to contact us if we can be of any further assistance

Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk

Chief Constable 4 August 2025

HM CORONER’S COURT BRISTOL BEFORE: ASSISTANT CORONER ROBERT SOWERSBY

IN THE INQUEST TOUCHING THE DEATH OF AMY LEVY

RESPONSE TO REGULATION 28 REPORT

1. Introduction
1.1 This response is provided on behalf of the Chief Constable of Surrey Police to assist His Majesty’s Assistant Coroner following the conclusion of the inquest into the death of Amy Levy and in response to the matters of concern raised in the Regulation 28 Report to Prevent Future Deaths dated 10th June 2025.
2. Legal and Regulatory Framework relevant to Preventing Future Deaths following an Inquest
2.1 This response is provided in accordance with Regulation 29 of The Coroners (Investigations) Regulations 2013, which requires that a person or organisation receiving a report under Regulation 28 must respond in writing within 56 days, either:
• Detailing the action that has been taken or which is proposed to be taken, including a timetable for action; or
• Explaining why no action is proposed.

2.2 Surrey Police recognises the importance of these reports in improving public safety and is committed to addressing concerns raised in the prevention of future deaths process.
3. Issues raised by His Majesty’s Assistant Coroner pursuant to the Inquest evidence
3.1 The inquest into the death of Amy Levy identified that she had contacted a friend indicating she had self-harmed and had taken an overdose, but her location was unknown. Collectively, two Police forces attempted to contact her family and friends in an effort to obtain her address or further information.
3.2 A key concern identified during the inquest was that although a number of phone calls were made by the police to her family and friends, no voicemail messages were left when those calls went unanswered. This meant that recipients may have been unaware of the urgency or source of the call, and which may have delayed a critical response.
3.3 In the Regulation 28 report, His Majesty’s Assistant Coroner noted that whilst Surrey Police had updated its ‘Deployment of Resources Procedure’ to include guidance around voicemail messaging, it was not clear whether the guidance applies only to control room staff or also extends to operational police officers.
3.4 His Majesty’s Assistant Coroner expressed concern that in the absence of clear, force- wide guidance or training, there remained a risk that future deaths could occur in similar circumstances.
4. Organisational Structure
4.1 Surrey Police’s Force Command Centre is the central hub for receiving and managing all emergency (999), non-emergency (101) calls and non-voice contact (which includes, but is not limited to, emails, texts, and social media posts).
4.2 Within the Force Command Centre, call takers gather information from the contact (a caller or via non-voice channels) and create incident logs, and dispatchers allocate appropriate police resources in real time.
4.3 The Force Command Centre operates under the oversight of a Silver (Chief Inspector) who provides operational leadership.
4.4 Surrey Police is divided into three geographical divisions, each with teams of frontline officers who respond to incidents. The divisions are supported by a centrally managed Operations Command, which provides specialist support (such as Dogs, Armed Response and Roads Policing).
4.5 Oversight of officer and staff training, adherence to policies and procedures and continuous professional development training is managed by the Learning and Professional Development department.

5. Action Taken by Surrey Police: Policy Update
5.1 Prior to the conclusion of the inquest, Surrey Police had already reviewed and updated its Deployment of Resources Procedure policy to include detailed guidance on contacting members of the public when seeking urgent information, including the appropriate use of voicemail messaging.
5.2 This updated procedure (Sections 13.7–13.13) now makes it clear that staff making calls to members of the public and dispatchers sending officers to incidents, must consider whether it is appropriate to leave a voicemail unless there is a compelling operational reason not to do so. Where a voicemail is left, it must:
• Identify that the call is from the police.
• Provide a reference number where relevant.
• Request a call back.
5.3 The updated procedure also includes safeguards to ensure no personal, sensitive, or case-specific information is left in the voicemail and sets out the requirement to record the rationale for the decision taken. The procedure further mandates that CADs (‘computer aided dispatch’ incident logs) must not be closed until it is clear that contact has been made or reasonable efforts to make contact have been exhausted. Scope of the Policy
5.4 Whilst this procedure is owned and used within the Force Command Centre by contact and dispatch staff, the principles it outlines are being embedded more broadly. This includes operational officers who may also make time-critical enquiries when seeking to locate a vulnerable person.
5.5 In response to the concern raised by the Coroner that the guidance may appear limited in scope, Surrey Police is now taking steps to ensure that this guidance is embedded force-wide, including through training and inclusion in relevant operational development programmes. Action in Progress: Training and Awareness
5.6 Learning and Professional Development is now incorporating this updated guidance into multiple training pathways. Specifically:
• All new Police Constables and Police Community Support Officers will receive training on voicemail practice as part of their initial training.
• It will be included in appropriate Detective training courses, as well as the Sergeant and Inspector promotion pathways.
• It will be embedded into the Initial Development Programme for Force Command Centre contact and dispatch staff. This is the team that receives initial contact from

members of the public and dispatches officers in response to operational calls and contact.
• The Continuous Professional Development team within Learning & Professional Development is developing options for wider inclusion via refresher sessions. Continuous Professional Development delivery is anticipated to begin from September 2025, subject to scheduling availability.
5.7 The updated guidance in the Surrey Police Deployment of Resources procedure and associated training pathways has been shared with the College of Policing to ensure alignment with any national best practice. We will keep our local approach under review in light of any future guidance issued by the College.
5.8 To ensure this learning is embedded across the force, Surrey Police are taking the following specific steps:
• Monitor compliance with the new procedure: The Deployment of Resources Procedure is a live document and subject to regular review. Updates are highlighted via briefing screens within the Force Command Centre. Compliance is audited through the Quality Control Team, who conduct structured reviews on key focus areas.
• Review training content and its effectiveness: All training content is subject to annual review by the Learning and Professional Development department. As part of the ongoing transformation of the department, an evaluation strategy will be embedded to assess effectiveness and knowledge retention, which will be fully implemented by mid-2026. In addition, for leadership courses, there will be a bi- annual evaluation with course leavers, starting from January 2026, to measure impact and identify gaps.
• Engagement with the College of Policing: The revised procedure and our plans to incorporate the guidance into training has been shared with the College to seek confirmation that it aligns with any forthcoming national standards. Engagement will continue until formal feedback is received.

6. Timetable for Action Action Status Owner Expected Completion Procedure update (voicemail guidance) Completed Deputy Head of Force Command Centre Prior to Inquest conclusion Training for new recruits and detectives In progress Head of Learning & Professional Development Ongoing (August 2025) onward Inclusion in promotion pathways (Sergeants/Inspectors) In progress Head of Learning & Professional Development Ongoing (September
2025) onward Embedding in the Initial Development Programme (call takers and dispatchers) In progress Head of Learning & Professional Development Ongoing (August 2025) onward Continuous Professional Development input across wider workforce Planned Head of Learning & Professional Development From September 2025 onward Engagement with College of Policing to ensure that national best practice is considered Ongoing Head of Learning & Professional Development From July 2025 onward

Dear Mr Sowersby, Chief Constable, Police Headquarters PO Box 37, Valley Road, Portishead, Bristol BS20 8QJ Date: 4 August 2025 RE: Response to Regulation 28 Report to Prevent Future Deaths Thank you for your conduct of the inquest touching on the death of Amy Levy and your report dated 10 June 2025. This is the response from Avon and Somerset Constabulary ("ASC") to the matter of concern which was identified. That matter of concern was as follows: "With limited or no guidance, training or policy on when police and/or police support staff liaising with the public should leave a voicemail (particularly in circumstances where they are trying to obtain important information in a time pressured situation), I am concerned that there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you." ASC accept the findings that there was limited training and policy in place which provided clear guidance to police and staff about when a voicemail should be left when attempting to make contact with a member of the public. ASC are committed to ensuring that changes to our training and policies reduce any ambiguity around this, and a full review has been carried out by our Professional Standards and Communications departments to consider improvements. The following changes will be implemented as a result:
1) The opening assessment of Amy's case by the ASC call handler upon the reported circumstances and the subsequent categorisation of the incident was 'suicidal' and the grading 'immediate'. In terms of an opening assessment and grading, these both, at the time, were appropriate. However, although 'suicidal' cases by their nature imply an immediate response and would be treated as such (as in Amy's case), there wasn't a dedicated force policy and procedure. As such, going forward, cases assessed as involving circumstances which would be categorised as 'suicidal' will follow the appropriate procedure under the Concern for Safety (Right Care Right Person) policy (where the person's whereabouts are known, expected or likely) or the Missing Person policy (whereabouts unknown). The call scripts used by the communications team have been updated to reflect this and it will be included in a bulletin, as well as featuring in the team's knowledge hub area, training, and tutorship books.

2) The Concern for Safety and Missing Person policies have been updated to include specific wording around the leaving of voicemails, as follows: In situations where the threshold has been met, indicating a real and immediate risk to life or of serious harm, and Police have undertaken to conduct enquiries, there may be situations requiring a telephone call to another party, for example family members. Where those enquiries include a telephone call to another party but where there has been no answer, an answerphone message must be left, and/or a text message must be sent, requesting a call back and including contact details. Details of this should be immediately added to the storm log and/or niche report. The leaving of an answerphone message, or a text, is not sufficient to demonstrate contact and does not negate the need for further attempts to be made until a callback from the other party is received, serving as confirmation of contact. The updated Concern for Welfare policy was published on 28 July 2025, and a copy is enclosed. The Missing Person policy is concurrently subject to a scheduled review, therefore once this review is complete an updated version will be published, and it is confirmed will include this wording.
3) Although not specifically identified as a matter of concern, the communications teams have been briefed that any telephone number passed to an ASC call handler must be confirmed after it has been typed on the incident log to ensure it is accurate. This is because it was identified that, during the incident, when Surrey Police passed the Levy family landline number to an ASC call handler, it was taken down incorrectly, and despite the ASC call handler repeating the number, the error was not identified by either handler. We believe our actions will therefore mitigate the risk of this occurring again.
4) All communications staff have received training regarding the updated policies and procedures, and briefings in respect of the lessons learnt from this incident. This was completed on 31 July 2025. Once again, we thank you for identifying the matters raised and hope this response addresses the concerns. We can confirm the College of Policing and the Independent Office for Police Conduct have also been kept updated and informed of the actions taken.