Dear Ms Syed Re Regulation 28 report following the inquest into the death of Hannah Beardshaw Thank you for your report dated 13 April 2022 in respect of the tragic death of Hannah Beardshaw and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009. Having carefully considered your report and the evidence submitted at the inquest I make the following observations and recommendations to hopefully address your matters of concern.
1. A delay in escalating the incident, resulting in almost a four hour delay to respond to the incident. GMP revisited it's Graded Response Policy (GRP) and made changes implementing a new GRP on the 1 February 2022. Incidents are now graded following a risk assessment via the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) framework and assessed on the information received as opposed to incident type or crime category. Incidents graded 1 are high risk incidents that require a response time within 15 minutes, incidents graded 2 are medium risk incidents that require a response time within 1 hour these are referred to as 'go now' incidents, incidents graded C are low risk incidents that can be responded to outside of 1 hour and are referred to as 'go later', C incidents are often dealt with by appointment at a time suitable to the victim in line with their needs. The new GRP incorporates escalation of grade 1 incidents to District Inspectors immediately following creation in the event that dispatch staff are unable to task or allocate a resource; and escalation of grade 2 incidents to district sergeants within 40 minutes in the event that dispatch staff are unable to task or allocate a resource, the responsibility is then on the district inspector/ sergeant to task a resource to respond to the incident to deliver a service to the public. All staff within the Force Contact Centre (FCC) have received training on THRIVE and the new GRP incorporating escalation. At shift changeover times if an incident has not been resourced within the target time frame for arrival, staff within the FCC will re escalate to district supervision. Stringent measurement of attendance times are in place with daily data produced for both FCC and district colleagues. Any incidents within the grade 1 and 2 queues that are over 24 hours old are flagged to District Silver Commanders by the FCC Supervisor responsible for that district at the district morning pacesetter meetings, via email or Teams message if insufficient supervisors are on duty within the FCC to have a dedicated supervisor per district. These in the main are grade 2 incidents where efforts to speak with the caller/victim have failed due to their availability and there is deemed no threat to life to warrant forced entry under S.17 PACE. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Contd pg 2 ... District Silver Commanders are the Superintendents or Chief Inspector's based on each district who have the responsibility for district resourcing that day. The FCC Supervisor will provide an update as follows:
• Numbers of grade 1 and 2 incidents in the incident queue for the respective district
• Number of deployable patrols provided by the district to the FCC
• Number of incidents allocated
• Any incident the FCC wish to raise for example a high risk missing from home that has just been created
• Any incidents in the incident queue that are over 24 hours old (these should be very few and are frequently as referred to above)
2. A failure to make method of entry kits more readily available to those trained in their use. Each GMP District or Branch has a Method of Entry (MOE) SPOC (Single Point of Contact) who is responsible for the maintenance, storage and ordering of MOE kit and equipment. Most districts have one central storage area of all MOE kit and some designated vehicles also have MOE equipment stored within them. During the initial training course, students are informed of this procedure/SOP during the delivery of the twelve MOE safety rules. How this equipment is distributed is determined by the individual districts or branches so upon their return from training, they will be familiarised with each district or Branch process. The SPOCs also have access to the GMP suppliers for ordering of new kit and equipment as and when it is required. The recommendation to the SPOC network as a result of this tragic incident has been the need to audit their equipment and identify where there is insufficient equipment available for trained officers. The Level 3 MOE training core syllabus covers the following:
• Legal inputs including National Decision Model (NDM), Code of Ethics, Powers of Entry and Human Rights.
• Use of the 'Lock Puller'.
• Use of the 'Enforcer'
• Use of levers As of 1 April 2016, Level 3 MOE officers must complete a three hour refresher course every three years. There are 192 course spaces available per year for Districts and Branches to book their front line officers onto. How they decide who or how many need to attend is a matter for each District but skill spread across teams and reliefs, inclusion within Performance Development Reviews (PDRs) are all factors taken into consideration as long as the individuals meet the following criteria:
• Job Related Fitness Test (JRFT) to level 5.4;
• A 'safe to use' lift and hold assessment; Up-to-date Personal Safety Training (PST). Should there be an evidenced demand for additional courses, the training team would look for opportunities within the training plan to accommodate this. Staff from within the Specialist Operational Training Department meet quarterly with District Resource Management Units (DRMUs) and so understand the demand picture for training and ensure MOE training provision and availability remains part of this agenda. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont pg 3 ... The learning identified from this incident will form part of the initial MOE L3 training going forward with the package being updated for future delivery. This will also be reflected for new student officers joining GMP on the PEQF pathway who receive initial training on legislation and powers of entry. It is also important that the key messages and learning from this tragic incident are conveyed to all other officers, particularly front line officers. In order to do this an article will be uploaded to the forces internal internet site and shared with the forces organisational learning team who publish a "Top 3" lessons message each month on which the learning from this incident will be conveyed. There has also been an updated Chief Constables Orders submission made for inclusion on the GMP Intranet to cover the MOE Levels, training opportunities and SOPs.
3. Improvement in document management The FCC is in the process of implementing a new and improved system that will replace Sherlock. Sherlock, the current system, holds information on policy and procedure however there are limited options with this system in terms of version control, updates and organisation. It is the FCC's intention to replace the whole system with a new platform which is already used within other departments of GMP. Developers have been spoken to who have confirmed that these requirements can be built in and it is anticipated to have the new system in place by August 2022. The project team are actively working on content which will take up to six weeks and the technical team are actively building the platform which will take around two weeks. The content will be migrated to the new system on weeks seven and eight. The system will then be tested on weeks nine and ten and training and implementation will be undertaken on weeks eleven and twelve. A project management group consisting of Subject Matter Experts (SME) from each area of the FCC has been set up who will review Sherlock content, archive outdated information and update policies and procedures as appropriate. Once the content is up to date it will be built into the new system which comes with additional benefits including much improved version control, with changes time stamped and saved, usage analytics, which will help identify skills gaps and required training material and it will be far more responsive in terms of time taken to locate information. The FCC are already familiar with the system as it is used for other tasks and so system navigation training should be simple to implement. Briefing notes and user guides will be developed and supervision will be given tutorials which they will then replicate with their teams. Previously there has been limited investment in the FCC both in terms of resources and technology which has greatly affected its ability to meet demand. This approach resulted in underperformance and poor staff retention along with a number of IT challenges. The newly agreed upon FCC investment plan demonstrates GMPs commitment to improving service delivery. The FCC are in the process of recruiting in all areas of business to stabilise performance. Improving standards is an area of focus in addition to investing in equipment, software and process improvements that underpin FCC service delivery. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Dear Miss Syed

Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Miss Hannah Beardshaw

Thank you for your report to prevent future deaths which I received on 14 April 2022. I am responding on behalf of , Director General of the Independent Office for Police Conduct (IOPC).

One of the IOPC’s strategic priorities is to improve policing by identifying and sharing learning from our work. While many investigations, appeals or reviews focus on individual learning, we also consider whether learning or improvement is needed at an organisational or national level.

We identify and share learning from our work through a variety of methods, including the use of our statutory powers to make organisational learning recommendations during or following an IOPC independent investigation.

The IOPC has the power to make such recommendations under both section 10 to the Police Reform Act 2002 and paragraph 28A of Schedule 3 to the Act. There are differences in the scope of these powers. Section 10 recommendations may be made to chief officers, local policing bodies and contractors. They may be made following or before the conclusion of an investigation, and may therefore be used for ‘quick-time learning’. Paragraph 28A recommendations may be made to the same bodies or any other organisation. They may only be made following an investigation. Where the IOPC makes a recommendation under paragraph 28A, the recipient must provide a written response within 56 days of the recommendation being made.

The IOPC’s independent investigation into the death of Miss Hannah Beardshaw identified four systemic issues where, as decision-maker for the investigation, I felt changes were required to policy, guidance, training, systems, and equipment to prevent similar incidents occurring.

The learning recommendations were set out in the IOPC final report, and an external consultation process commenced with Greater Manchester Police on 25 April 2022. The purpose of the external consultation was to receive input and feedback on the proposed

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recommendations, to help refine the recommendations to ensure they were factually accurate, effective in addressing the issue, achievable, and timely.

We received a response from Greater Manchester Police to the proposed recommendations on 16 May 2022. I understand Greater Manchester Police will share their proposals with you directly in response to their Regulation 28 Report to Prevent Future Deaths.

On 24 May 2022, I gave approval for all four learning recommendations to be formally issued to Greater Manchester Police in accordance with the IOPC powers under Paragraph 28A of Schedule 3 of the Police Reform Act 2002. The four recommendations are:

1) The IOPC recommends that Greater Manchester Police takes steps to ensure that the staff within the Force Control Centre understand the importance of the escalation policy and the individual responsibilities laid out within the policy for escalating incidents when they have been left unresourced for a period of time exceeding the targets for that grade. GMP could consider issuing communications to staff on these matters and/or ensuring that they are covered in appropriate training.

2) The IOPC recommends that Greater Manchester Police incorporates, if possible, a system prompt on ControlWorks specifically for control room supervisors to alert supervisors when a log has been unresourced for a period of time that exceeds the target for the incidents grade.

3) The IOPC recommends that Greater Manchester Police takes steps to make method of entry (MOE) equipment more readily available to officers when the need for MOE equipment arises. This could include assigning MOE tools to MOE trained officers at the beginning of their tour of duty.

4) The IOPC recommends that Greater Manchester Police takes steps to improve their record keeping and archiving around when changes are made to the Call Handling Minimum Standards. This could be achieved by way of implementing a version control system on any changes to the standards, making sure to document the date of the change, who made the change, the reason for the change, and specifically what has changed compared to the previous version. In addition, previous versions should be appropriately archived and dated for when they were in effect from and to.

Greater Manchester Police now have a legal obligation to respond to the recommendations in writing by 20 July 2022. Their response must include details of the action they have taken or intend to take in response to the recommendations or, why they have not taken, or do not propose to take, any action in response to the recommendations. Our recommendations will be published on our website. We shall also publish GMP’s response unless they make representations that all or any part of their response should not be published. If we receive such representations, I will make a final decision on the publication of GMP’s response to our recommendations.

May I take this opportunity to thank you for your Report to Prevent Future Deaths. I am in full agreement that the learning that was identified by the IOPC’s independent

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investigation may prevent future deaths and, as such, it is of vital importance that action is taken by Greater Manchester Police.