Elaine Tarbuck
PFD Report
All Responded
Ref: 2025-0342
All 3 responses received
· Deadline: 1 Sep 2025
Coroner's Concerns (AI summary)
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
View full coroner's concerns
During the Inquest, evidence was heard that:
1. Family members who lived far from the deceased became concerned for the welfare of the deceased and were of the view that she had suffered a medical episode, collapse or adverse event that explained her failure to respond to telephone calls and knocks on the door from friends.
2. The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased’s residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.
3. In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event. This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.
4. There was lack of understanding as to whether the forced entry would be lawful, a matter for the police, or a matter for Fire and Rescue Services in circumstances that the next-of-kin, if asked, would have agreed readily to there being forced entry at the outset and well before their arrival.
5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler.
6. The emergency response had come about because of a new ‘Right Care, Right Person’ policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased’s residence.
7. Prior to the implementation of ‘Right Care, Right Person’ this ‘concern for welfare’ emergency would have been dealt with by the attendance of the police on the scene as first responders who would have been likely to have achieved entry as a result of the concern for welfare.
1. Family members who lived far from the deceased became concerned for the welfare of the deceased and were of the view that she had suffered a medical episode, collapse or adverse event that explained her failure to respond to telephone calls and knocks on the door from friends.
2. The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased’s residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.
3. In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event. This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.
4. There was lack of understanding as to whether the forced entry would be lawful, a matter for the police, or a matter for Fire and Rescue Services in circumstances that the next-of-kin, if asked, would have agreed readily to there being forced entry at the outset and well before their arrival.
5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler.
6. The emergency response had come about because of a new ‘Right Care, Right Person’ policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased’s residence.
7. Prior to the implementation of ‘Right Care, Right Person’ this ‘concern for welfare’ emergency would have been dealt with by the attendance of the police on the scene as first responders who would have been likely to have achieved entry as a result of the concern for welfare.
Responses
Action Planned
GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. (AI summary)
GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. (AI summary)
View full response
Dear Mr Brennand RE: Regulation 28 report following the death of Elaine Tarbuck Thank you for your report dated 7th July 2025 in respect of the death of Elaine Tarbuck pursuant paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Having carefully considered your report, I make the following observations and recommendations in relation to the matters of concern, which are understood to be the following broad areas - the evaluation and assessment of concern for welfare (CFW) calls (including information gathering and training in these areas), forcing entry and the appropriate agency to do so and ensuring the appropriate agency responds to such incidents. GMP’s handling of CFW relating to Mrs Tarbuck GMP were contacted at 1131 hours on the 29"' March 2025 and informed of a concern for Mrs Tarbuck. This call was made via 999 by a friend of Mrs Tarbuck who was present outside Mrs Tarbuck’s address. Having attended for a pre-arranged visit to his friend, he couldn't get a response from Mrs Tarbuck and thought something was wrong. The caller was informed that the police were not the most appropriate agency to attend this incident and the caller was signposted to the North West Ambulance Service (NWAS) as a more appropriate agency to progress the concern. During this call no information relating to Mrs T arbuck having a history of falls nor any perception that Mrs Tarbuck was to be considered at high risk to have suffered intentional physical harm was disclosed to the police call handler (and GMP understand there was no concern that Mrs Tarbuck may have deliberately self-harmed). The police call handler was informed that a family member believed there was a possibility Mrs Tarbuck could have fallen inside the premises and the caller stated that he did not believe Mrs Tarbuck to have fallen but that she could be deceased inside the property. This comment was made by the caller in response to the police call handler suggesting that an ambulance would be the most appropriate agency to respond to a person believed to have suffered a fall.
Cont.d pg 2 GMP’s response to CFW under Right Care, Right Person (RCRP) aligns with its legal obligations under Articles 2 and 3 European Convention on Human Rights (ECHR) (right to life and prohibition of torture). As such it is imperative that call handlers fully understand the nature of concern to allow for an effective assessment as to whether police deployment is required. Both aforementioned comments should have elicited further questioning from the police call handler to understand the circumstances and risks associated with this incident and the basis of these comments but unfortunately this further questioning did not take place. At the time of call handling, appropriate questioning had not been carried out. Very few questions were asked by the police call handler to understand the circumstances and risks associated with this incident. The call handler did not thoroughly question the caller to fully understand the incident being reported and they appear to have already formulated the assumption that NWAS were the most appropriate agency to manage this CFW before all the information was gathered. Appropriate feedback has been provided to the call handler involved. GMP accepts that there were suboptimal elements to the way in which the concern for Mrs Tarbuck was handled, including a lack of professional curiosity in the level and manner of questioning, the language used and that insufficient information was gathered to support the identification and assessment of risk. The RCRP assessment tool, designed to support call handlers to identify the most appropriate agency to progress the incident, was not completed until after the call had ended. The family of Mrs Tarbuck were of the view that she may have fallen and it transpired that Mrs Tarbuck had in fact fallen within the premises. NWAS accepted the incident and responded within a timeframe they deemed appropriate for the nature of concern and utilised the Greater Manchester Fire & Rescue Service (GMFRS) Gaining Entry Memorandum of Understanding (MoU) processes as intended (outlined further in this report). It is acknowledged that the questioning and identification of risk was sub-optimal, meaning there was insufficient evidence or good reason to confirm either a location or a physical health need (both of which are required deployment criteria for NWAS). As the caller and Mrs Tarbuck’s daughter believed she had indeed fallen and/or was deceased within her home address, however, further questioning by the police call handler would likely have identified the evidence to support the notion that NWAS was the most appropriate emergency agency to attend to address a medical concern. As as such, the advice to contact NWAS was in line with RCRP principles. This incident has subsequently been the subject of a debrief between GMP and NWAS and NWAS have stated that a lack of reasonable grounds to support both a confirmed location and a confirmed physical health concern would likely, in future, result in NWAS refusing to respond. Should there be any disagreement between agencies, there is a professional inter-agency escalation procedure in place, enabling communication to take place between agencies swiftly and directly. GMP acknowledge this position and understand that this has been the operational stance of NWAS since the implementation of RCRP within Greater Manchester.
Cont.d pg 3 Right Care, Right Person Right Care Right Person (RCRP) is a national approach supported by the Home Office and the College of Policing designed to ensure that people of all ages, who have physical, mental health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. GMP’s RCRP project was developed under the oversight of Greater Manchester’s Deputy Mayor. Each thematic response pathway was agreed prior to launch with relevant partners including (but not limited to) local authorities, health services (including NWAS) and mental health service providers. RCRP was launched in Greater Manchester on the 30th September 2024. Under RCRP, when a concern for welfare (CFW) is reported, GMP will strive to identify the nature of the concern and either deploy police resources or signpost the caller to the most appropriate agency to meet their needs. CFW calls are often complicated and can consist of numerous issues across various thematic areas. Whilst RCRP aims to signpost the caller to the most appropriate service to meet their needs, it is acknowledged that this may not always be possible, and the complexity of such calls may require the services of more than one organisation to support the subject of the CFW call. In cases involving more than one concern, GMP will signpost to the most appropriate organisation to address whichever concern GMP feels is the most pressing or primary concern. The RCRP policy and procedure is predominantly aimed at staff and officers within the Force Crime, Contact and Operations (FCCO) branch who manage all incoming 999 and 101 calls to GMP, including those relating to a CFW. However, the policy will also enable officers and staff throughout the organisation to ensure they act in line with the principles of RCRP. It aims to ensure that any response to a request for service is focused on the needs of the individual and where necessary, partner agencies are engaged to provide the most appropriate response. GMP’s RCRP policy seeks to affirm the police's duty to deal with core policing responsibilities, which are:
• To prevent and detect crime;
• To keep the King’s peace;
• To protect life and property. If the initial RCRP assessment identifies that police are the most appropriate agency to respond, resources will be deployed in a manner and timescale appropriate to the identified risk. This response will be in line with current deployment timescales (i.e. Immediate or grade 1 incidents - within 15 minutes; Priority or grade 2 -within 1 hour; and all other incidents for progression via a more ‘slow time’ response). If an initial RCRP assessment identifies that police are not the most appropriate agency to take ownership, the caller will be informed of this decision and then signposted to the most appropriate agency to address the concern.
Cont.d pg 4 In Greater Manchester, aligned to national RCRP principles, the following thematic areas and associated signposting pathways have been designed to assist in handling CFW calls under RCRP:
• Physical Health
• Mental Health
• Social Issues Understanding the nature of concern By assessing each CFW call via an RCRP assessment tool, call handlers should be able to determine the nature of the concern. The RCRP assessment tool is a bespoke question set which is built into GMP’s command and control system, meaning call handlers have immediate access to the relevant question set at the time of incident creation and importantly whilst obtaining information from a caller reporting a CFW. It has been designed to assist call handlers to identify the nature of the concern and whether the police are the most appropriate agency to respond or whether the CFW can be better facilitated by a partner agency. A number of GMP policies outline an expectation for call handlers to be professionally curious when handling initial calls with the aim of correctly identifying and assessing risk. The RCRP-policy is no exception to this. The following relevant passages are all found within the RCRP policy and procedure document:
• Call handlers/CRROs (Crime Recording and Resolution Officers) should ask questions of the caller to ensure that the circumstances of each call are fully understood so a decision can be made as to whether it is a matter for the police to accept. As such call handlers should remain professionally curious and ask any questions, they deem relevant.
• It is paramount that call handlers/CRROs recognise any identified risk and if necessary are professionally curious to ensure understanding. It is acceptable to question informants to quantify a perceived risk.
• Often when people are reporting an incident to the police, they are not clear as to what they want the police to do. The importance of understanding what is being reported should not be underestimated. Call handlers/CRROs have a key role to play here in asking questions to the caller to understand the detail. As well as using the RCRP assessment tool, call handlers / CRROs are expected to refer to the service standards as set out in Sherlock (defined below) and encouraged to ask further questions in order to be satisfied as to the exact nature of the call. Handling Physical Health concerns The concern for welfare incident relating to Mrs Tarbuck was considered a physical health concern by the police call handler and as such the caller was signposted to contact NWAS. GMP are not the most appropriate agency to respond to physical health matters. Call Handlers are trained to use the RCRP assessment tool which assists them in identifying whether an incident involves a real and immediate risk to life or risk of serious harm, but they are not trained to triage physical health concerns or identify a suitable operational response to such concerns. As such, under RCRP, GMP will not ordinarily provide a policing response to physical health concerns.
Cont.d pg 5 NWAS are the appropriate organisation to remotely assess physical health concerns reported to them, by members of the public and GMP. Where the nature of a CFW call relates to a physical health concern, GMP will signpost the caller to the NHS and/or NWAS. GMP will only respond to physical health concerns when there is an associated immediate risk of harm to a partner agency /third party or there is a requirement for police to assist (via a specific police function/core responsibility). Under the physical health pathway, if the caller thinks their concern is a physical health emergency they are signposted to contact NWAS via 999. A partnership agreement formalising this physical health pathway was signed by representatives of GMP and NWAS in October 2024, but it was informally in place prior to this time. In April 2024, NWAS clarified their operational stance that they will provide emergency ambulance services for people with a confirmed location. NWAS has defined ‘confirmed location’ to capture circumstances whereby the caller has evidence or good reason to believe that the patient or service user is at a location, and who have a confirmed physical health issue, or mental health need with a co-associated physical need. NWAS has defined a ‘confirmed physical or mental health complaint’ to capture circumstances whereby “the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires an ambulance response”. Right Care, Right Person training Prior to the launch of RCRP, all relevant staff were provided with training overseen by a Detective Chief Inspector from GMPs RCRP project team. Initial training was delivered in May 2024, followed by refresher sessions in September 2024. This training covered various RCRP elements including areas pertinent to incidents similar to the handling of the concern for Mrs Tarbuck as outlined below;
• Identifying Real, Immediate Risk to Life: Assessment Criteria: This section of the training provides guidance on the specific criteria used to determine if there is an immediate threat to life in line with Article 2 ECHR, including factors such as the presence of weapons, threats
• of violence, and signs of severe distress. It defines what is meant by real and immediate as per policy and lists definitions of the specific incidents the police will still be responsible for.
• Response Protocols: This section detail steps to be taken when an immediate risk is identified. This includes contacting emergency services if other services are needed, responding to the incident and taking ownership of it.
• Referral Process: Lists steps for referring individuals to appropriate partner agencies. This includes sign posting callers to appropriate physical health services and the use of the medical contingency process.
• THRIVE Quality (THRIVE - Threat, Harm, Vulnerability, Investigation, Vulnerability, Engage) is the standardised format for risk assessment used by GMP call handlers.
Cont.d pg 6 An explanation of the THRIVE model, which is used for assessing and responding to various situations involving risk was captured within the training. This includes understanding the different components of the model and how they apply to real-life scenarios.
• Quality Assurance: Measures to ensure the quality and consistency of THRIVE assessments. Examples were provided of good quality THRIVE assessments shortly after implementation to ensure better understanding of what was acceptable.
• Risk Principles: Outlining the College of Policing Risk Principles to remind participants of the necessity to make good decisions backed by strong rationale and documentation. Call handlers were initially supported by a number of subject matter experts (SME’s) from the RCRP project team who had enhanced training and knowledge of RCRP. The SME’s were available 24/7 to embed the principles of RCRP and support call handling staff when handling CFW calls. For the two-week period after RCRP went live in GMP, on-site support was also provided by SME’s from the Metropolitan Police Service, who launched RCRP in November 2023 and Humberside Police who are credited with developing RCRP and who went live in 2020. Gaining entry on behalf of NWAS In April 2024, GMP, NWAS and GMFRS signed the “Gaining Entry Memorandum of Understanding”. The purpose of the MoU is to outline a process to guide NWAS in circumstances whereby they needed to gain entry into premises to assess patients who require an emergency clinical assessment. Under this MoU, GMFRS are the primary agency to support NWAS when forced entry is required at a premises. GMFRS will utilise their powers under the Fire and Rescue Service Act 2004, specifically Part 2 section 11, which notes: (1) A fire and rescue authority may take any action it considers appropriate— (a) in response to an event or situation of a kind mentioned in subsection (2); (b) for the purpose of enabling action to be taken in response to such an event or situation. (2) The event or situation is one that causes or is likely to cause— (a) one or more individuals to die, be injured or become ill; If NWAS require assistance with gaining entry they will contact North West Fire Control (NWFC). NWAS must have allocated a resource to the given address or to be already in attendance for GMFRS to attend a category one call. NWAS provide a category one response ‘for people with life-threatening injuries and illnesses’. GMFRS will only attend category two, three and four incidents once NWAS resource is in attendance. NWAS provide a category two response ‘for people whose injuries and illnesses may not be life-threatening but still require emergency care’ and a category three response ‘for people who require urgent help, but it isn’t an emergency’. If GMFRS cannot respond to a request to force entry owing to other emergency situations then NWFC will request that GMP attend. These measures were agreed by all three organisations (GMFRS, NWAS and GMP) and ensure that support to force entry can be provided to NWAS by either GMFRS or GMP when required.
Cont.d pg 7 The most relevant legislation relied upon by police to effect entry when dealing with a CFW is Section 17(1)(e) Police and Criminal Evidence (PACE) Act 1984 which states that a constable may enter and search premises for the purpose of saving life or limb or preventing serious damage to property. The case of Syed v Director of Public Prosecutions [201 0] EWHC 81 (Admin) provides guidance in relation to the police use of S17 PACE when the reason for their entry was a concern for someone’s welfare. In Syed v DPP, the court ruled that “Concern for welfare is not sufficient to justify an entry within the terms of s. 1 7(1)(e). It is altogether too low a test. I appreciate and have some sympathy with the problems that face police officers in a situation such as was faced by these officers. In a sense they are damned if they do and damned if they do not, because if in fact something serious had happened, or was about to happen, and they did not do anything about it because they took the view that they had no right of entry, no doubt there would have been a degree of ex post facto criticism. But it is important to bear in mind that Parliament set the threshold at the height indicated by s. 17(1)(e) because it is a serious matter for a citizen to have his house entered against his will and by force by police officers. Parliament having set that level, it is important that it be met in any particular case”. Whilst the findings of Syed v DPP do not bar police from utilising their powers under S17 PACE when responding to a CFW, it is clear that the threshold for police to force entry is higher (saving life and limb having been interpreted in Baker v Crown Prosecution Service [2009] EWHC 299 (Admin) as meaning ‘apprehended serious bodily injury’) than that required by the fire and rescue services under the Fire and Rescue Services Act 2004 (situations...likely to cause...individuals to die, be injured or become ill). In addition to the lower threshold required for GMFRS to force entry, the deployment of GMFRS resources to CFW incidents provides an improved service to the communities of Greater Manchester by improving response times (as it is often the case that GMFRS has a greater capacity than police to respond promptly to requests to force entry in support of NWAS). GMFRS also often has ready access to more advanced equipment to effect entry than that carried by response police officers, thereby facilitating earlier access to the patient. The Gaining Entry MoU provides clear roles and responsibilities for each agency when forced entry is required by NWAS, removing any potential confusion between agencies as to who will attend to force entry. In the case of Mrs Tarbuck, having signposted the caller to NWAS, all relevant agencies were clear in their understanding of the Gaining Entry MoU. As NWAS were the agency taking the lead on this CFW, GMFRS would be the primary agency to force entry, if requested to do so by NWAS. Learning and subsequent developments Since the implementation of RCRP in September 2024, GMP has undertaken a series of measures to improve compliance and mitigate risks. GMP have reviewed the application of RCRP in a number of cases since its introduction. Learningfrom those reviews has identified themes of sub optimal information gathering and risk assessment, lack of professional curiosity and a proclivity to signpost callers to NWAS when a confirmed physical health concern has not been identified.
Cont.d pg 8 As such, a number of measures have been implemented to address these concerns. To support understanding of, and adherence to RCRP policy, including the expectation that call handlers are professionally curious and fully understand the nature of concern, enhanced scrutiny and oversight processes have been set up within the Force Contact, Crime and Operations branch (FCCO) of GMP. Such scrutiny includes performance audits, dip sampling, use of personal performance plans where necessary and a bespoke "FCCO Performance Dashboard", which pulls together audits and tracks key metrics such as RCRP toolkit compliance and accuracy of signposting. To support improved information gathering a new RCRP assessment tool was developed in early 2025. This new assessment tool was developed with the aim of supporting call handlers to better navigate the often- complicated nature of CFW calls and their interdependencies with other areas of business. This new assessment tool is currently undergoing testing within the FCCO. The proposed assessment tool will seamlessly link various thematic areas into one. It will provide a framework that will allow call handlers to navigate multiple themes without a having to shift their mindset from one policy area to another. The assessment tool currently in use covers only CFW and then signposts the user to consider other policy areas such as missing persons (without navigating the user through such processes). The new toolkit is expected to cover the following areas:
• CFW (Mental health, Physical Health, Social Issues)
• Improved CFW & Crime outcomes
• Missing Persons o Missing Adults o Missing Children
• AWOL Patients
• Walkout from Healthcare
• Child concerns - Child information sharing processes. As part of their daily business, call handlers often use a computer system within GMP known as Sherlock. Sherlock is a directory that contains guidance and service standards that call handlers can access to better understand the area of business relevant to the call they are handling. As part of the RCRP implementation, a number of new guidance documents were produced and installed into the Sherlock system to support call handlers understand relevant RCRP processes and police functions and obligations in relation to CFW calls. These guidance documents are located in folders thatare accessed by call handlers if/when they require additional guidance. Call handlers need to understand which piece of guidance is relevant at the relevant point of incident handling, often multiple pieces of information would need to be accessed for a single call. Within the proposed assessment tool, this guidance is presented on screen at relevant points within the question framework, meaning that users see the right information at the right time, displayed alongside the relevant question of the assessment tool. This obviates the need to search Sherlock to find a particular
Cont.d pg 9 piece of information, thus presenting opportunities to improve consistency of service and reduces the possibility of misunderstanding and the mis-categorisation of a particular incident. This upgraded version is currently undergoing testing and is expected to be rolled out by November 2025. Whilst testing of the new RCRP assessment tool is ongoing, GMP’s RCRP project team is currently reviewing the current assessment tool to ascertain if amendments can be made to better support call handlers in understanding the nature of concern and to ensure they are professionally curious when managing CFW calls. This work is currently focusing on the wording and order of the question scripts as well as considering whether further questions can be added to the assessment tool to improve service delivery. Actions have already commenced to amend the language of both toolkits to incorporate NWAS’ definitions of ‘confirmed location’ and ‘confirmed physical health need’ to ensure improved consistency and understanding between GMP and NWAS when handling CFW incidents. Within the proposed assessment tool these definitions will appear on screen, to prompt call handers to ask the pertinent questions to identify the concern. Training and education have been central to our improvement strategy. Bespoke workshops for the Service Development Unit and leadership teams are planned to be delivered during the week commencing 1st September 2025. These workshops are designed to effectively calibrate managers and SPOCs, using recent case studies and inquest findings to refresh their knowledge of RCRP pathways and policy. Relevant staff have received additional training around the THRIVE model to ensure consistent and effective risk assessment and decision-making across all RCRP-related incidents. Initial THRIVE training was delivered to all staff between August 2023 and February 2024, and all new staff continue to receive THRIVE training as part of their induction. This model underpins GMP’s approach to prioritising incidents and allocating resources, ensuringthat responses are proportionate, appropriate, and aligned with the principles of RCRP. Where audit findings identify issues with the application of THRIVE assessments, staff are required to undertake refresher training and are subsequently monitored and supported to ensure compliance and a clear understanding of the model To support the ongoing understanding of RCRP, further training has been developed that will align with the proposed assessment tool. This training has been created within the Nearpod system. Nearpod is a third- party training platform which allows users to access modular training relevant to their training needs and provides bite-sized yet informative inputs, available when required to upskill staff. This training is currently being utilised, pending the trial of the new assessment tool. RCRP refresher training for call handling managers and supervisors is currently being developed by the original RCRP training team with support from the RCRP project team as well as upskilling inputs for GMP’s Service development Unit (SDU - the unit responsible for auditing and reviewing RCRP incident handling). This training and upskilling is expected to be in place by the end of 2025. GMP’s RCRP project team are working closely with NWAS and other police forces, including those in which RCRP has been implemented for a longer period, to understand working practice within other force areas to identify and benchmark best practice that can be quickly adopted by GMP to further improve standards.
Cont.d pg 10 GMP’s FCCO branch oversee the application and compliance of RCRP by call handling staff. Overseen by Rebecca Greaney, Head of Contact Management and Business Transformation, who has provided the below overview of remedial measures to address issues identified in the handling of RCRP incidents. FCCO have implemented a new governance framework to mitigate further risk which includes a fortnightly SLT meeting, which will bring together Business Leads and Superintendents across all areas of the Branch. The agenda will cover:
• Tracking performance. To monitor performance, GMP has developed a live dashboard that tracks key metrics for RCRP-related incidents. These include whether callers were signposted via an agreed pathway. Initial audit data from February 2025 indicated that 87% of incidents were signposted correctly. Subsequent audits conducted in June and July 2025 (n=277) show marked improvements with signposting accuracy having increased to 94%.
• Fortnightly SDU feedback using amended audit methodology (this complements a wider change to the FCCO audit plan whereby Managers and Business Leads will be required to audit the work of the teams to offer consistency and reassurance).
• Track individual supportive performance plans across the teams including supervisors if/when necessary.
• Track Robotic Processing Audit (RPA) results GMP’s commitment to continuous improvement is demonstrated through the establishment of the RCRP Learning Group (RCRPLG), chaired by ACC Matt Boyle in his capacity as RCRP Gold. The RCRPLG was established in March 2025 and runs on a bi-monthly basis, with the most recent meeting held on 1 5th July
2025. It serves as the primary forum for reviewing operational practice, thematic concerns, and policy matters related to RCRP. Its purpose is to identify learning, support professional development, and ensure consistent and coordinated improvements across the organisation. The group works closely with GMP’s organisational learning structures and considers both internal and national best practice. Membership includes representatives from key branches and partner agencies, ensuring that learning is embedded and shared effectively. Additional work is ongoing to further educate call handlers around signposting and the communication strategy has been revisited. This ongoing activity includes:
• Northwest Ambulance Service (NWAS) knowledge sharing - to strengthen collaboration and understanding, weekly meetings have been introduced between the FCCO and NWAS Senior Leadership Teams to share feedback and concerns regarding signposting between both organisations. NWAS will also support weekly GMP performance meetings (held with team managers and supervisors on a 5x week rota) to share case studies and learning.
• Knowledge-sharing visits between FCCO and NWAS commenced on 14th July 2025 and remain ongoing, with the most recent taking place on 4th August 2025. GMP control room staff visit NWAS’ control rooms to promote better partnership working and understanding of organisation issues and impact. These visits include first and second line leaders, with identified supervisor SPOCs tasked with cascading learning across their teams.
Cont.d pg 11
• 10x supervisor SPOCS (Specialist Point Of Contact) identified - 2x per call handling team. These SPOCS will attend the NWAS site visits and have been tasked with cascading the learning to the individuals across their teams on their return. They will also be tasked with upskilling their staff and will spend time with GMP’s RCRP subject matter experts to further educate them on the thematic challenges identified across the Branch.
• Communication strategy - Wider communication has been circulated to supervisors and managers within the FCCO as a reminder about expectations, standards and behaviour particularly addressing the key risks. Communication strategies have been reinforced through digital wallboards and regular messaging to supervisors and managers. These communications are designed to maintain awareness of key RCRP principles and support continuous improvement. Recent examples include the use of case studies from live incidents and inquests to highlight learning points, the sharing of audit findings to identify areas for improvement, and reminders about correct pathway usage under the RCRP framework. These targeted messages ensure that staff remain informed, aligned, and equipped to apply the policy consistently.
• Robotic Process Automation (RPA) and technical enhancements - RPA has been implemented and can be flexed as required to measure performance and standards. Current priorities are to target the use of formal end statements, THRIVE and Police National Computer Checks. The RPA is limited to a quantitative compliance check rather than a qualitative assessment but allows compliance issues to be addressed quickly and individuals to be managed via performance plans if required and the behaviour persists. Technological enhancements are also being pursued with the design of further toolkit style products that guide call handlers through relevant questions to ensure standardisation and improved compliance.
• RCRP policy re-read - To reinforce policy understanding, the FCCO is currently conducting an audit of all staff who have a role within the RCRP processes, including staff and supervisors within call handling, crime recording, customer enquiry unit and radio dispatch to ensure there is a record confirming they have read and understood the RCRP policy. All relevant staff have been given protected time to read the RCRP policy and subsequently confirm this has been completed via a Microsoft Form. This audit is expected to be completed by the end of August 2025. This audit also includes support mechanisms forthose identified as not fully understanding their role once the policy has been read. This includes access to RCRP subject matter experts to provide clarification around any points of misunderstanding or ambiguity. These plans are now in place to mitigate the risks identified, driven by the FCCO Senior Leadership Team and supported by the RCRP project team. The governance for progress is to be tracked within the FCCO via a fortnightly branch meeting chaired by Head of Contact Management. Further governance will be via the RCRP Silver group (chaired at Chief Superintendent rank) and RCRP Gold group (chaired at Assistant Chief Constable rank). FCCO senior leaders will measure improvements by audit results, partner feedback and ongoing project team scrutiny. The FCCO Senior leadership team are committed to implementing the mitigations listed to help ensure these risks are minimised.
Cont.d pg 12 A robust wraparound support plan is in place to monitorthe implementation for RCRP. This includes regular internal and partnership governance meetings at a strategic and tactical level, escalation processes in both live and slow time and an opportunity to share partner data to assess the impact of the implementation of the model. Looking ahead, GMP aims to sustain signposting accuracy at or above 94% and improve toolkit compliance to 90% or higher. A revised audit plan was implemented in June 2025 and now includes assessments of supervisory decision-making to strengthen accountability and oversight. These actions reflect GMP’s commitment to continuous improvement and to ensuring that the principles of RCRP are embedded across all levels of the organisation. I trust that the detail within this letter serves to demonstrate the considerable amount of work is underway to address the matters of concern, to improve the standards of call handling specifically around the understanding and identification of risk and work continues to ensure the Right Care, Right Person model is embedded safely within Greater Manchester, to ensure the communities of Greater Manchester are responded to by the right person, with the right skills, training, and experience to best meet their needs.
Cont.d pg 2 GMP’s response to CFW under Right Care, Right Person (RCRP) aligns with its legal obligations under Articles 2 and 3 European Convention on Human Rights (ECHR) (right to life and prohibition of torture). As such it is imperative that call handlers fully understand the nature of concern to allow for an effective assessment as to whether police deployment is required. Both aforementioned comments should have elicited further questioning from the police call handler to understand the circumstances and risks associated with this incident and the basis of these comments but unfortunately this further questioning did not take place. At the time of call handling, appropriate questioning had not been carried out. Very few questions were asked by the police call handler to understand the circumstances and risks associated with this incident. The call handler did not thoroughly question the caller to fully understand the incident being reported and they appear to have already formulated the assumption that NWAS were the most appropriate agency to manage this CFW before all the information was gathered. Appropriate feedback has been provided to the call handler involved. GMP accepts that there were suboptimal elements to the way in which the concern for Mrs Tarbuck was handled, including a lack of professional curiosity in the level and manner of questioning, the language used and that insufficient information was gathered to support the identification and assessment of risk. The RCRP assessment tool, designed to support call handlers to identify the most appropriate agency to progress the incident, was not completed until after the call had ended. The family of Mrs Tarbuck were of the view that she may have fallen and it transpired that Mrs Tarbuck had in fact fallen within the premises. NWAS accepted the incident and responded within a timeframe they deemed appropriate for the nature of concern and utilised the Greater Manchester Fire & Rescue Service (GMFRS) Gaining Entry Memorandum of Understanding (MoU) processes as intended (outlined further in this report). It is acknowledged that the questioning and identification of risk was sub-optimal, meaning there was insufficient evidence or good reason to confirm either a location or a physical health need (both of which are required deployment criteria for NWAS). As the caller and Mrs Tarbuck’s daughter believed she had indeed fallen and/or was deceased within her home address, however, further questioning by the police call handler would likely have identified the evidence to support the notion that NWAS was the most appropriate emergency agency to attend to address a medical concern. As as such, the advice to contact NWAS was in line with RCRP principles. This incident has subsequently been the subject of a debrief between GMP and NWAS and NWAS have stated that a lack of reasonable grounds to support both a confirmed location and a confirmed physical health concern would likely, in future, result in NWAS refusing to respond. Should there be any disagreement between agencies, there is a professional inter-agency escalation procedure in place, enabling communication to take place between agencies swiftly and directly. GMP acknowledge this position and understand that this has been the operational stance of NWAS since the implementation of RCRP within Greater Manchester.
Cont.d pg 3 Right Care, Right Person Right Care Right Person (RCRP) is a national approach supported by the Home Office and the College of Policing designed to ensure that people of all ages, who have physical, mental health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. GMP’s RCRP project was developed under the oversight of Greater Manchester’s Deputy Mayor. Each thematic response pathway was agreed prior to launch with relevant partners including (but not limited to) local authorities, health services (including NWAS) and mental health service providers. RCRP was launched in Greater Manchester on the 30th September 2024. Under RCRP, when a concern for welfare (CFW) is reported, GMP will strive to identify the nature of the concern and either deploy police resources or signpost the caller to the most appropriate agency to meet their needs. CFW calls are often complicated and can consist of numerous issues across various thematic areas. Whilst RCRP aims to signpost the caller to the most appropriate service to meet their needs, it is acknowledged that this may not always be possible, and the complexity of such calls may require the services of more than one organisation to support the subject of the CFW call. In cases involving more than one concern, GMP will signpost to the most appropriate organisation to address whichever concern GMP feels is the most pressing or primary concern. The RCRP policy and procedure is predominantly aimed at staff and officers within the Force Crime, Contact and Operations (FCCO) branch who manage all incoming 999 and 101 calls to GMP, including those relating to a CFW. However, the policy will also enable officers and staff throughout the organisation to ensure they act in line with the principles of RCRP. It aims to ensure that any response to a request for service is focused on the needs of the individual and where necessary, partner agencies are engaged to provide the most appropriate response. GMP’s RCRP policy seeks to affirm the police's duty to deal with core policing responsibilities, which are:
• To prevent and detect crime;
• To keep the King’s peace;
• To protect life and property. If the initial RCRP assessment identifies that police are the most appropriate agency to respond, resources will be deployed in a manner and timescale appropriate to the identified risk. This response will be in line with current deployment timescales (i.e. Immediate or grade 1 incidents - within 15 minutes; Priority or grade 2 -within 1 hour; and all other incidents for progression via a more ‘slow time’ response). If an initial RCRP assessment identifies that police are not the most appropriate agency to take ownership, the caller will be informed of this decision and then signposted to the most appropriate agency to address the concern.
Cont.d pg 4 In Greater Manchester, aligned to national RCRP principles, the following thematic areas and associated signposting pathways have been designed to assist in handling CFW calls under RCRP:
• Physical Health
• Mental Health
• Social Issues Understanding the nature of concern By assessing each CFW call via an RCRP assessment tool, call handlers should be able to determine the nature of the concern. The RCRP assessment tool is a bespoke question set which is built into GMP’s command and control system, meaning call handlers have immediate access to the relevant question set at the time of incident creation and importantly whilst obtaining information from a caller reporting a CFW. It has been designed to assist call handlers to identify the nature of the concern and whether the police are the most appropriate agency to respond or whether the CFW can be better facilitated by a partner agency. A number of GMP policies outline an expectation for call handlers to be professionally curious when handling initial calls with the aim of correctly identifying and assessing risk. The RCRP-policy is no exception to this. The following relevant passages are all found within the RCRP policy and procedure document:
• Call handlers/CRROs (Crime Recording and Resolution Officers) should ask questions of the caller to ensure that the circumstances of each call are fully understood so a decision can be made as to whether it is a matter for the police to accept. As such call handlers should remain professionally curious and ask any questions, they deem relevant.
• It is paramount that call handlers/CRROs recognise any identified risk and if necessary are professionally curious to ensure understanding. It is acceptable to question informants to quantify a perceived risk.
• Often when people are reporting an incident to the police, they are not clear as to what they want the police to do. The importance of understanding what is being reported should not be underestimated. Call handlers/CRROs have a key role to play here in asking questions to the caller to understand the detail. As well as using the RCRP assessment tool, call handlers / CRROs are expected to refer to the service standards as set out in Sherlock (defined below) and encouraged to ask further questions in order to be satisfied as to the exact nature of the call. Handling Physical Health concerns The concern for welfare incident relating to Mrs Tarbuck was considered a physical health concern by the police call handler and as such the caller was signposted to contact NWAS. GMP are not the most appropriate agency to respond to physical health matters. Call Handlers are trained to use the RCRP assessment tool which assists them in identifying whether an incident involves a real and immediate risk to life or risk of serious harm, but they are not trained to triage physical health concerns or identify a suitable operational response to such concerns. As such, under RCRP, GMP will not ordinarily provide a policing response to physical health concerns.
Cont.d pg 5 NWAS are the appropriate organisation to remotely assess physical health concerns reported to them, by members of the public and GMP. Where the nature of a CFW call relates to a physical health concern, GMP will signpost the caller to the NHS and/or NWAS. GMP will only respond to physical health concerns when there is an associated immediate risk of harm to a partner agency /third party or there is a requirement for police to assist (via a specific police function/core responsibility). Under the physical health pathway, if the caller thinks their concern is a physical health emergency they are signposted to contact NWAS via 999. A partnership agreement formalising this physical health pathway was signed by representatives of GMP and NWAS in October 2024, but it was informally in place prior to this time. In April 2024, NWAS clarified their operational stance that they will provide emergency ambulance services for people with a confirmed location. NWAS has defined ‘confirmed location’ to capture circumstances whereby the caller has evidence or good reason to believe that the patient or service user is at a location, and who have a confirmed physical health issue, or mental health need with a co-associated physical need. NWAS has defined a ‘confirmed physical or mental health complaint’ to capture circumstances whereby “the caller has evidence or good reason to believe that the patient or service user is currently suffering from a physical or mental health issue that requires an ambulance response”. Right Care, Right Person training Prior to the launch of RCRP, all relevant staff were provided with training overseen by a Detective Chief Inspector from GMPs RCRP project team. Initial training was delivered in May 2024, followed by refresher sessions in September 2024. This training covered various RCRP elements including areas pertinent to incidents similar to the handling of the concern for Mrs Tarbuck as outlined below;
• Identifying Real, Immediate Risk to Life: Assessment Criteria: This section of the training provides guidance on the specific criteria used to determine if there is an immediate threat to life in line with Article 2 ECHR, including factors such as the presence of weapons, threats
• of violence, and signs of severe distress. It defines what is meant by real and immediate as per policy and lists definitions of the specific incidents the police will still be responsible for.
• Response Protocols: This section detail steps to be taken when an immediate risk is identified. This includes contacting emergency services if other services are needed, responding to the incident and taking ownership of it.
• Referral Process: Lists steps for referring individuals to appropriate partner agencies. This includes sign posting callers to appropriate physical health services and the use of the medical contingency process.
• THRIVE Quality (THRIVE - Threat, Harm, Vulnerability, Investigation, Vulnerability, Engage) is the standardised format for risk assessment used by GMP call handlers.
Cont.d pg 6 An explanation of the THRIVE model, which is used for assessing and responding to various situations involving risk was captured within the training. This includes understanding the different components of the model and how they apply to real-life scenarios.
• Quality Assurance: Measures to ensure the quality and consistency of THRIVE assessments. Examples were provided of good quality THRIVE assessments shortly after implementation to ensure better understanding of what was acceptable.
• Risk Principles: Outlining the College of Policing Risk Principles to remind participants of the necessity to make good decisions backed by strong rationale and documentation. Call handlers were initially supported by a number of subject matter experts (SME’s) from the RCRP project team who had enhanced training and knowledge of RCRP. The SME’s were available 24/7 to embed the principles of RCRP and support call handling staff when handling CFW calls. For the two-week period after RCRP went live in GMP, on-site support was also provided by SME’s from the Metropolitan Police Service, who launched RCRP in November 2023 and Humberside Police who are credited with developing RCRP and who went live in 2020. Gaining entry on behalf of NWAS In April 2024, GMP, NWAS and GMFRS signed the “Gaining Entry Memorandum of Understanding”. The purpose of the MoU is to outline a process to guide NWAS in circumstances whereby they needed to gain entry into premises to assess patients who require an emergency clinical assessment. Under this MoU, GMFRS are the primary agency to support NWAS when forced entry is required at a premises. GMFRS will utilise their powers under the Fire and Rescue Service Act 2004, specifically Part 2 section 11, which notes: (1) A fire and rescue authority may take any action it considers appropriate— (a) in response to an event or situation of a kind mentioned in subsection (2); (b) for the purpose of enabling action to be taken in response to such an event or situation. (2) The event or situation is one that causes or is likely to cause— (a) one or more individuals to die, be injured or become ill; If NWAS require assistance with gaining entry they will contact North West Fire Control (NWFC). NWAS must have allocated a resource to the given address or to be already in attendance for GMFRS to attend a category one call. NWAS provide a category one response ‘for people with life-threatening injuries and illnesses’. GMFRS will only attend category two, three and four incidents once NWAS resource is in attendance. NWAS provide a category two response ‘for people whose injuries and illnesses may not be life-threatening but still require emergency care’ and a category three response ‘for people who require urgent help, but it isn’t an emergency’. If GMFRS cannot respond to a request to force entry owing to other emergency situations then NWFC will request that GMP attend. These measures were agreed by all three organisations (GMFRS, NWAS and GMP) and ensure that support to force entry can be provided to NWAS by either GMFRS or GMP when required.
Cont.d pg 7 The most relevant legislation relied upon by police to effect entry when dealing with a CFW is Section 17(1)(e) Police and Criminal Evidence (PACE) Act 1984 which states that a constable may enter and search premises for the purpose of saving life or limb or preventing serious damage to property. The case of Syed v Director of Public Prosecutions [201 0] EWHC 81 (Admin) provides guidance in relation to the police use of S17 PACE when the reason for their entry was a concern for someone’s welfare. In Syed v DPP, the court ruled that “Concern for welfare is not sufficient to justify an entry within the terms of s. 1 7(1)(e). It is altogether too low a test. I appreciate and have some sympathy with the problems that face police officers in a situation such as was faced by these officers. In a sense they are damned if they do and damned if they do not, because if in fact something serious had happened, or was about to happen, and they did not do anything about it because they took the view that they had no right of entry, no doubt there would have been a degree of ex post facto criticism. But it is important to bear in mind that Parliament set the threshold at the height indicated by s. 17(1)(e) because it is a serious matter for a citizen to have his house entered against his will and by force by police officers. Parliament having set that level, it is important that it be met in any particular case”. Whilst the findings of Syed v DPP do not bar police from utilising their powers under S17 PACE when responding to a CFW, it is clear that the threshold for police to force entry is higher (saving life and limb having been interpreted in Baker v Crown Prosecution Service [2009] EWHC 299 (Admin) as meaning ‘apprehended serious bodily injury’) than that required by the fire and rescue services under the Fire and Rescue Services Act 2004 (situations...likely to cause...individuals to die, be injured or become ill). In addition to the lower threshold required for GMFRS to force entry, the deployment of GMFRS resources to CFW incidents provides an improved service to the communities of Greater Manchester by improving response times (as it is often the case that GMFRS has a greater capacity than police to respond promptly to requests to force entry in support of NWAS). GMFRS also often has ready access to more advanced equipment to effect entry than that carried by response police officers, thereby facilitating earlier access to the patient. The Gaining Entry MoU provides clear roles and responsibilities for each agency when forced entry is required by NWAS, removing any potential confusion between agencies as to who will attend to force entry. In the case of Mrs Tarbuck, having signposted the caller to NWAS, all relevant agencies were clear in their understanding of the Gaining Entry MoU. As NWAS were the agency taking the lead on this CFW, GMFRS would be the primary agency to force entry, if requested to do so by NWAS. Learning and subsequent developments Since the implementation of RCRP in September 2024, GMP has undertaken a series of measures to improve compliance and mitigate risks. GMP have reviewed the application of RCRP in a number of cases since its introduction. Learningfrom those reviews has identified themes of sub optimal information gathering and risk assessment, lack of professional curiosity and a proclivity to signpost callers to NWAS when a confirmed physical health concern has not been identified.
Cont.d pg 8 As such, a number of measures have been implemented to address these concerns. To support understanding of, and adherence to RCRP policy, including the expectation that call handlers are professionally curious and fully understand the nature of concern, enhanced scrutiny and oversight processes have been set up within the Force Contact, Crime and Operations branch (FCCO) of GMP. Such scrutiny includes performance audits, dip sampling, use of personal performance plans where necessary and a bespoke "FCCO Performance Dashboard", which pulls together audits and tracks key metrics such as RCRP toolkit compliance and accuracy of signposting. To support improved information gathering a new RCRP assessment tool was developed in early 2025. This new assessment tool was developed with the aim of supporting call handlers to better navigate the often- complicated nature of CFW calls and their interdependencies with other areas of business. This new assessment tool is currently undergoing testing within the FCCO. The proposed assessment tool will seamlessly link various thematic areas into one. It will provide a framework that will allow call handlers to navigate multiple themes without a having to shift their mindset from one policy area to another. The assessment tool currently in use covers only CFW and then signposts the user to consider other policy areas such as missing persons (without navigating the user through such processes). The new toolkit is expected to cover the following areas:
• CFW (Mental health, Physical Health, Social Issues)
• Improved CFW & Crime outcomes
• Missing Persons o Missing Adults o Missing Children
• AWOL Patients
• Walkout from Healthcare
• Child concerns - Child information sharing processes. As part of their daily business, call handlers often use a computer system within GMP known as Sherlock. Sherlock is a directory that contains guidance and service standards that call handlers can access to better understand the area of business relevant to the call they are handling. As part of the RCRP implementation, a number of new guidance documents were produced and installed into the Sherlock system to support call handlers understand relevant RCRP processes and police functions and obligations in relation to CFW calls. These guidance documents are located in folders thatare accessed by call handlers if/when they require additional guidance. Call handlers need to understand which piece of guidance is relevant at the relevant point of incident handling, often multiple pieces of information would need to be accessed for a single call. Within the proposed assessment tool, this guidance is presented on screen at relevant points within the question framework, meaning that users see the right information at the right time, displayed alongside the relevant question of the assessment tool. This obviates the need to search Sherlock to find a particular
Cont.d pg 9 piece of information, thus presenting opportunities to improve consistency of service and reduces the possibility of misunderstanding and the mis-categorisation of a particular incident. This upgraded version is currently undergoing testing and is expected to be rolled out by November 2025. Whilst testing of the new RCRP assessment tool is ongoing, GMP’s RCRP project team is currently reviewing the current assessment tool to ascertain if amendments can be made to better support call handlers in understanding the nature of concern and to ensure they are professionally curious when managing CFW calls. This work is currently focusing on the wording and order of the question scripts as well as considering whether further questions can be added to the assessment tool to improve service delivery. Actions have already commenced to amend the language of both toolkits to incorporate NWAS’ definitions of ‘confirmed location’ and ‘confirmed physical health need’ to ensure improved consistency and understanding between GMP and NWAS when handling CFW incidents. Within the proposed assessment tool these definitions will appear on screen, to prompt call handers to ask the pertinent questions to identify the concern. Training and education have been central to our improvement strategy. Bespoke workshops for the Service Development Unit and leadership teams are planned to be delivered during the week commencing 1st September 2025. These workshops are designed to effectively calibrate managers and SPOCs, using recent case studies and inquest findings to refresh their knowledge of RCRP pathways and policy. Relevant staff have received additional training around the THRIVE model to ensure consistent and effective risk assessment and decision-making across all RCRP-related incidents. Initial THRIVE training was delivered to all staff between August 2023 and February 2024, and all new staff continue to receive THRIVE training as part of their induction. This model underpins GMP’s approach to prioritising incidents and allocating resources, ensuringthat responses are proportionate, appropriate, and aligned with the principles of RCRP. Where audit findings identify issues with the application of THRIVE assessments, staff are required to undertake refresher training and are subsequently monitored and supported to ensure compliance and a clear understanding of the model To support the ongoing understanding of RCRP, further training has been developed that will align with the proposed assessment tool. This training has been created within the Nearpod system. Nearpod is a third- party training platform which allows users to access modular training relevant to their training needs and provides bite-sized yet informative inputs, available when required to upskill staff. This training is currently being utilised, pending the trial of the new assessment tool. RCRP refresher training for call handling managers and supervisors is currently being developed by the original RCRP training team with support from the RCRP project team as well as upskilling inputs for GMP’s Service development Unit (SDU - the unit responsible for auditing and reviewing RCRP incident handling). This training and upskilling is expected to be in place by the end of 2025. GMP’s RCRP project team are working closely with NWAS and other police forces, including those in which RCRP has been implemented for a longer period, to understand working practice within other force areas to identify and benchmark best practice that can be quickly adopted by GMP to further improve standards.
Cont.d pg 10 GMP’s FCCO branch oversee the application and compliance of RCRP by call handling staff. Overseen by Rebecca Greaney, Head of Contact Management and Business Transformation, who has provided the below overview of remedial measures to address issues identified in the handling of RCRP incidents. FCCO have implemented a new governance framework to mitigate further risk which includes a fortnightly SLT meeting, which will bring together Business Leads and Superintendents across all areas of the Branch. The agenda will cover:
• Tracking performance. To monitor performance, GMP has developed a live dashboard that tracks key metrics for RCRP-related incidents. These include whether callers were signposted via an agreed pathway. Initial audit data from February 2025 indicated that 87% of incidents were signposted correctly. Subsequent audits conducted in June and July 2025 (n=277) show marked improvements with signposting accuracy having increased to 94%.
• Fortnightly SDU feedback using amended audit methodology (this complements a wider change to the FCCO audit plan whereby Managers and Business Leads will be required to audit the work of the teams to offer consistency and reassurance).
• Track individual supportive performance plans across the teams including supervisors if/when necessary.
• Track Robotic Processing Audit (RPA) results GMP’s commitment to continuous improvement is demonstrated through the establishment of the RCRP Learning Group (RCRPLG), chaired by ACC Matt Boyle in his capacity as RCRP Gold. The RCRPLG was established in March 2025 and runs on a bi-monthly basis, with the most recent meeting held on 1 5th July
2025. It serves as the primary forum for reviewing operational practice, thematic concerns, and policy matters related to RCRP. Its purpose is to identify learning, support professional development, and ensure consistent and coordinated improvements across the organisation. The group works closely with GMP’s organisational learning structures and considers both internal and national best practice. Membership includes representatives from key branches and partner agencies, ensuring that learning is embedded and shared effectively. Additional work is ongoing to further educate call handlers around signposting and the communication strategy has been revisited. This ongoing activity includes:
• Northwest Ambulance Service (NWAS) knowledge sharing - to strengthen collaboration and understanding, weekly meetings have been introduced between the FCCO and NWAS Senior Leadership Teams to share feedback and concerns regarding signposting between both organisations. NWAS will also support weekly GMP performance meetings (held with team managers and supervisors on a 5x week rota) to share case studies and learning.
• Knowledge-sharing visits between FCCO and NWAS commenced on 14th July 2025 and remain ongoing, with the most recent taking place on 4th August 2025. GMP control room staff visit NWAS’ control rooms to promote better partnership working and understanding of organisation issues and impact. These visits include first and second line leaders, with identified supervisor SPOCs tasked with cascading learning across their teams.
Cont.d pg 11
• 10x supervisor SPOCS (Specialist Point Of Contact) identified - 2x per call handling team. These SPOCS will attend the NWAS site visits and have been tasked with cascading the learning to the individuals across their teams on their return. They will also be tasked with upskilling their staff and will spend time with GMP’s RCRP subject matter experts to further educate them on the thematic challenges identified across the Branch.
• Communication strategy - Wider communication has been circulated to supervisors and managers within the FCCO as a reminder about expectations, standards and behaviour particularly addressing the key risks. Communication strategies have been reinforced through digital wallboards and regular messaging to supervisors and managers. These communications are designed to maintain awareness of key RCRP principles and support continuous improvement. Recent examples include the use of case studies from live incidents and inquests to highlight learning points, the sharing of audit findings to identify areas for improvement, and reminders about correct pathway usage under the RCRP framework. These targeted messages ensure that staff remain informed, aligned, and equipped to apply the policy consistently.
• Robotic Process Automation (RPA) and technical enhancements - RPA has been implemented and can be flexed as required to measure performance and standards. Current priorities are to target the use of formal end statements, THRIVE and Police National Computer Checks. The RPA is limited to a quantitative compliance check rather than a qualitative assessment but allows compliance issues to be addressed quickly and individuals to be managed via performance plans if required and the behaviour persists. Technological enhancements are also being pursued with the design of further toolkit style products that guide call handlers through relevant questions to ensure standardisation and improved compliance.
• RCRP policy re-read - To reinforce policy understanding, the FCCO is currently conducting an audit of all staff who have a role within the RCRP processes, including staff and supervisors within call handling, crime recording, customer enquiry unit and radio dispatch to ensure there is a record confirming they have read and understood the RCRP policy. All relevant staff have been given protected time to read the RCRP policy and subsequently confirm this has been completed via a Microsoft Form. This audit is expected to be completed by the end of August 2025. This audit also includes support mechanisms forthose identified as not fully understanding their role once the policy has been read. This includes access to RCRP subject matter experts to provide clarification around any points of misunderstanding or ambiguity. These plans are now in place to mitigate the risks identified, driven by the FCCO Senior Leadership Team and supported by the RCRP project team. The governance for progress is to be tracked within the FCCO via a fortnightly branch meeting chaired by Head of Contact Management. Further governance will be via the RCRP Silver group (chaired at Chief Superintendent rank) and RCRP Gold group (chaired at Assistant Chief Constable rank). FCCO senior leaders will measure improvements by audit results, partner feedback and ongoing project team scrutiny. The FCCO Senior leadership team are committed to implementing the mitigations listed to help ensure these risks are minimised.
Cont.d pg 12 A robust wraparound support plan is in place to monitorthe implementation for RCRP. This includes regular internal and partnership governance meetings at a strategic and tactical level, escalation processes in both live and slow time and an opportunity to share partner data to assess the impact of the implementation of the model. Looking ahead, GMP aims to sustain signposting accuracy at or above 94% and improve toolkit compliance to 90% or higher. A revised audit plan was implemented in June 2025 and now includes assessments of supervisory decision-making to strengthen accountability and oversight. These actions reflect GMP’s commitment to continuous improvement and to ensuring that the principles of RCRP are embedded across all levels of the organisation. I trust that the detail within this letter serves to demonstrate the considerable amount of work is underway to address the matters of concern, to improve the standards of call handling specifically around the understanding and identification of risk and work continues to ensure the Right Care, Right Person model is embedded safely within Greater Manchester, to ensure the communities of Greater Manchester are responded to by the right person, with the right skills, training, and experience to best meet their needs.
Action Taken
NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. (AI summary)
NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. (AI summary)
View full response
Dear Mr Brennand
We write in reference to the Regulation 28 report issued to Greater Manchester Police in connection with the sad death of Ms Elaine Tarbuck.
We understand that North West Ambulance Service (NWAS) were not Interested Persons and did not receive a disclosure bundle therefore, we are limited in terms of the information we hold in respect of the incident. We felt a response to your concern was required as we aim to provide the court with any assistance if we are able.
In terms of NWAS we note your concern as follows:
‘In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event. This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.’
NWAS received a call at 11:52hrs which was coded as a Category 3 response and arrived at 12:18hrs, which is within the Ambulance Response Programme timeframes set by NHS England.
As part of the collaborative efforts between NWAS, North West Police Forces, and wider system partners in the implementation of the Right Care, Right Person (RCRP) model, NWAS formally provided its organisational position on responding to Concern for Welfare calls in 2024. The below details our organisational response to ‘Concern for Welfare’ calls.
Confirmed Location.
• NWAS are not equipped to conduct inquiries or execute searches for missing individuals. Consequently, NWAS necessitate a verified location and assurance that the patient is indeed present at the specified location where an ambulance resource is being dispatched to. Additionally, NWAS rely on accurate contact information, ensuring that any provided contact number will connect us directly with the patient.
• A confirmed location means that the caller has evidence or good reason to believe that the patient is at the location provided.
• NWAS does not have the legal powers, nor the equipment to force entry to properties, this should be considered before any call for assistance is made.
Confirmed Physical or Mental Health Complaint.
• As an ambulance service, NWAS’s primary function is to prioritise and respond to the medical needs of patients, whether this is face-to-face or via other methods, therefore, it is not the expected primary response for those who have no medical need to require our assistance.
• A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that a patient or service user is currently suffering from a physical or mental health issue which requires either a face-to-face assessment or telephone response.
• It cannot be assumed that an individual who is contactable, is in need of medical assistance. Similarly, patients who have left a healthcare facility have the right to do so, therefore the rationale as to what role an ambulance response will play and whether it is ethical and legal to dispatch one to a patient who has refused care or treatment must be provided.
Whilst it is acknowledged that, in the case of Ms Tarbuck, NWAS did deploy a resource following a call made to us, it is important to note that this deployment was not in line with our current procedures for Concern for Welfare incidents.
Based on the information provided at the time of the call, there was insufficient evidence of a confirmed location or a clear medical need, both of which are required criteria for ambulance deployment under the NWAS Concern for Welfare procedure.
NWAS, in partnership with Greater Manchester Police (GMP), has identified a recurring thematic issue involving calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare as outlined in the Right Care, Right Person stakeholder meetings. These concerns have been formally escalated to Senior Leaders within GMP and to the Deputy Mayor for further consideration and action.
In response, a number of collaborative measures have been implemented to address this issue and strengthen inter- agency working. These include:
• Delivery of targeted training briefs to enhance understanding of the Concern for Welfare criteria.
• Review of incident logs to identify trends and learning opportunities.
• Visits by GMP supervisors and managers to the NWAS control room to observe triage and decision-making processes in real time.
• Ongoing regular meetings between NWAS and GMP leadership teams to monitor progress, share insights, and maintain alignment.
These initiatives contribute to ongoing improved collaboration and aim to reduce the risks associated with inappropriate call transfers, and shared understanding of service commissioning gaps which require review by commissioning colleagues.
NWAS remains fully committed to working in partnership with GMP to support their ongoing implementation of the Right Care, Right Person approach. Our focus continues to be on maintaining patient safety, ensuring appropriate use of emergency resources, and identifying further opportunities for collaboration that strengthen service delivery across both organisations.
We trust that you are satisfied with NWAS’s response but please do not hesitate to contact us should you have any further questions or concerns and we will do our very best to assist you.
We write in reference to the Regulation 28 report issued to Greater Manchester Police in connection with the sad death of Ms Elaine Tarbuck.
We understand that North West Ambulance Service (NWAS) were not Interested Persons and did not receive a disclosure bundle therefore, we are limited in terms of the information we hold in respect of the incident. We felt a response to your concern was required as we aim to provide the court with any assistance if we are able.
In terms of NWAS we note your concern as follows:
‘In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event. This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.’
NWAS received a call at 11:52hrs which was coded as a Category 3 response and arrived at 12:18hrs, which is within the Ambulance Response Programme timeframes set by NHS England.
As part of the collaborative efforts between NWAS, North West Police Forces, and wider system partners in the implementation of the Right Care, Right Person (RCRP) model, NWAS formally provided its organisational position on responding to Concern for Welfare calls in 2024. The below details our organisational response to ‘Concern for Welfare’ calls.
Confirmed Location.
• NWAS are not equipped to conduct inquiries or execute searches for missing individuals. Consequently, NWAS necessitate a verified location and assurance that the patient is indeed present at the specified location where an ambulance resource is being dispatched to. Additionally, NWAS rely on accurate contact information, ensuring that any provided contact number will connect us directly with the patient.
• A confirmed location means that the caller has evidence or good reason to believe that the patient is at the location provided.
• NWAS does not have the legal powers, nor the equipment to force entry to properties, this should be considered before any call for assistance is made.
Confirmed Physical or Mental Health Complaint.
• As an ambulance service, NWAS’s primary function is to prioritise and respond to the medical needs of patients, whether this is face-to-face or via other methods, therefore, it is not the expected primary response for those who have no medical need to require our assistance.
• A confirmed physical or mental health complaint means that the caller has evidence or good reason to believe that a patient or service user is currently suffering from a physical or mental health issue which requires either a face-to-face assessment or telephone response.
• It cannot be assumed that an individual who is contactable, is in need of medical assistance. Similarly, patients who have left a healthcare facility have the right to do so, therefore the rationale as to what role an ambulance response will play and whether it is ethical and legal to dispatch one to a patient who has refused care or treatment must be provided.
Whilst it is acknowledged that, in the case of Ms Tarbuck, NWAS did deploy a resource following a call made to us, it is important to note that this deployment was not in line with our current procedures for Concern for Welfare incidents.
Based on the information provided at the time of the call, there was insufficient evidence of a confirmed location or a clear medical need, both of which are required criteria for ambulance deployment under the NWAS Concern for Welfare procedure.
NWAS, in partnership with Greater Manchester Police (GMP), has identified a recurring thematic issue involving calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare as outlined in the Right Care, Right Person stakeholder meetings. These concerns have been formally escalated to Senior Leaders within GMP and to the Deputy Mayor for further consideration and action.
In response, a number of collaborative measures have been implemented to address this issue and strengthen inter- agency working. These include:
• Delivery of targeted training briefs to enhance understanding of the Concern for Welfare criteria.
• Review of incident logs to identify trends and learning opportunities.
• Visits by GMP supervisors and managers to the NWAS control room to observe triage and decision-making processes in real time.
• Ongoing regular meetings between NWAS and GMP leadership teams to monitor progress, share insights, and maintain alignment.
These initiatives contribute to ongoing improved collaboration and aim to reduce the risks associated with inappropriate call transfers, and shared understanding of service commissioning gaps which require review by commissioning colleagues.
NWAS remains fully committed to working in partnership with GMP to support their ongoing implementation of the Right Care, Right Person approach. Our focus continues to be on maintaining patient safety, ensuring appropriate use of emergency resources, and identifying further opportunities for collaboration that strengthen service delivery across both organisations.
We trust that you are satisfied with NWAS’s response but please do not hesitate to contact us should you have any further questions or concerns and we will do our very best to assist you.
Action Planned
The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews. (AI summary)
The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews. (AI summary)
View full response
Dear Mr Brennand Thank you for your report dated 7 July 2025 concerning the tragic death of Elaine Tarbuck. We extend our sincere condolences to her family and all those affected. We have carefully considered the matters of concern raised in your Regulation 28 report. This response of the Right Care, Right Person (RCRP) approach, particularly regarding the role of the police in welfare- related calls and the issue of forced entry. Clarifying the Role of the Police in Welfare Calls The College recognises the public expectation that emergency services will respond swiftly and powers of entry is clear: unless there is a real and immediate risk to life or of serious harm (as defined under Articles 2 and 3 of the ECHR), or a crime is suspected, police powers to enter a private dwelling are limited. The RCRP toolkit, developed in partnership with the NPCC and other national agencies, reinforces this legal position. The section that specifically relates to the force control room can be found on the following link https://www.college.police.uk/guidance/right-care-right-person-toolkit/force-control-room- implementation-guidance It explicitly states that there is no general power of entry for welfare checks reaffirming the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states It also encourages forces to work with partners particularly the Fire and Rescue Service who may have the appropriate powers, training and equipment to gain entry in such circumstances. Please see an extract below and relevant link: Protocols will need to be developed at a local partnership level to set out the lines of responsibility for each agency. Once agreed, these changes to ways of working must be communicated to staff within each agency and guidance provided.
Addressing Delays and Improving Call Handling The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear. Clarifying Responsibilities for Forced Entry The confusion over which agency should take responsibility for forced entry is a key learning point. The RCRP guidance encourages local partnerships to develop clear protocols that define roles and responsibilities in such scenarios. These protocols should be communicated effectively to all frontline staff to avoid hesitation or uncertainty during time-critical incidents. We are working with forces and partner agencies to support the development and dissemination of these local agreements, and we will highlight this issue at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared. Responding to Concerns About the RCRP Model The intent of RCRP is to ensure individuals received the most appropriate care from the most appropriate agency. However, we understand the concerns and recognise that its implementation must be sensitive to the nuances of real-world emergencies. The College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews such as this. Commitment to Continuous Improvement The College remains committed to supporting forces in delivering lawful, proportionate, and effective responses to concern-for-welfare calls. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. We will continue to: Review and update national guidance based on emerging learning Support forces in developing local protocols with partner agencies Promote national consistency through the RCRP Tactical Delivery Board Encourage a culture of continuous improvement and reflective practice We hope this response provides assurance of our commitment to addressing the issues raised and to preventing future deaths in similar circumstances. Please do not hesitate to contact us should you require any further information.
Addressing Delays and Improving Call Handling The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear. Clarifying Responsibilities for Forced Entry The confusion over which agency should take responsibility for forced entry is a key learning point. The RCRP guidance encourages local partnerships to develop clear protocols that define roles and responsibilities in such scenarios. These protocols should be communicated effectively to all frontline staff to avoid hesitation or uncertainty during time-critical incidents. We are working with forces and partner agencies to support the development and dissemination of these local agreements, and we will highlight this issue at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared. Responding to Concerns About the RCRP Model The intent of RCRP is to ensure individuals received the most appropriate care from the most appropriate agency. However, we understand the concerns and recognise that its implementation must be sensitive to the nuances of real-world emergencies. The College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews such as this. Commitment to Continuous Improvement The College remains committed to supporting forces in delivering lawful, proportionate, and effective responses to concern-for-welfare calls. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. We will continue to: Review and update national guidance based on emerging learning Support forces in developing local protocols with partner agencies Promote national consistency through the RCRP Tactical Delivery Board Encourage a culture of continuous improvement and reflective practice We hope this response provides assurance of our commitment to addressing the issues raised and to preventing future deaths in similar circumstances. Please do not hesitate to contact us should you require any further information.
Sent To
- College Of Policing
- Greater Manchester Police
Response Status
Linked responses
3 of 2
56-Day Deadline
1 Sep 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 31 March 2025 I commenced an investigation into the death of Elaine TARBUCK aged 69. The Investigation concluded at the end of the Inquest on 25 June 2025.
The medical cause of death was:
1a) Exsanguination 1b) Scalp Laceration
2) Ischaemic Heart Disease
I returned a narrative conclusion that Elaine Tarbuck died as the consequence of injuries sustained in an accidental fall and the exacerbating effects of pre-existing naturally occurring disease on a background of sub-optimal emergency response.
The medical cause of death was:
1a) Exsanguination 1b) Scalp Laceration
2) Ischaemic Heart Disease
I returned a narrative conclusion that Elaine Tarbuck died as the consequence of injuries sustained in an accidental fall and the exacerbating effects of pre-existing naturally occurring disease on a background of sub-optimal emergency response.
Circumstances of the Death
The deceased had a medical history that included Multiple Myeloma with reducing mobility, a history of falls (previous pelvic fracture in November 2024) and low mood, depression and anxiety following the recent death of her husband. Such was the nature extent of concern for welfare, her next-of-kin (who resided a long distance from the deceased) would telephone the deceased several times in the day and had also arranged for family friends to visit daily. She was last spoken to during the evening of the 28th of March 2025.
At about 9.40am on the morning of 29th of March 2025, a friend of the deceased attended at her residence at , Westhoughton on a pre-arranged welfare visit. Upon obtaining no response from the deceased, he went to the nearest police station to report his concerns. Little Hulton Police Station was unmanned and closed, but public signage giving advice resulted in a call to the police ‘101’ non-emergency contact line. The concerned friend was instructed that the matter was a welfare and not a policing matter.
At 11.52am having confirmed from family and neighbours that the deceased had not been seen and was still not responding to telephone calls to her, the emergency services were contacted via a ‘999’ call. Call handlers determined that an ambulance should attend. Emergency paramedics arrived on scene at 12.18pm but could not gain access to the deceased’s property. The Fire Service was therefore requested to attend.
Following a forced entry via rear patio doors at 12.50pm the deceased was discovered in a collapsed, unresponsive condition at the foot of the stairs laying in a pool of dried blood from an obvious head injury. She was verified as dead and beyond any attempted resuscitation.
The evidence established that after setting the house alarms and heading up the stairs for bed during the preceding evening, the deceased had missed her footing or lost her balance, falling backwards from about three stairs up, landing in a way that caused her to lose immediate consciousness and having also sustained a laceration to her head, thereafter was to exsanguinate without re-gaining consciousness.
By reason of the time at which death could be established, it was determined that accepted suboptimal elements in the assessment, quality of questions asked of people contacting the police and emergency services and the resulting information gathering fell below the standard expected and applied as part of the ‘Right Care, Right Person’ response policy, this did not have any bearing upon the outcome.
At about 9.40am on the morning of 29th of March 2025, a friend of the deceased attended at her residence at , Westhoughton on a pre-arranged welfare visit. Upon obtaining no response from the deceased, he went to the nearest police station to report his concerns. Little Hulton Police Station was unmanned and closed, but public signage giving advice resulted in a call to the police ‘101’ non-emergency contact line. The concerned friend was instructed that the matter was a welfare and not a policing matter.
At 11.52am having confirmed from family and neighbours that the deceased had not been seen and was still not responding to telephone calls to her, the emergency services were contacted via a ‘999’ call. Call handlers determined that an ambulance should attend. Emergency paramedics arrived on scene at 12.18pm but could not gain access to the deceased’s property. The Fire Service was therefore requested to attend.
Following a forced entry via rear patio doors at 12.50pm the deceased was discovered in a collapsed, unresponsive condition at the foot of the stairs laying in a pool of dried blood from an obvious head injury. She was verified as dead and beyond any attempted resuscitation.
The evidence established that after setting the house alarms and heading up the stairs for bed during the preceding evening, the deceased had missed her footing or lost her balance, falling backwards from about three stairs up, landing in a way that caused her to lose immediate consciousness and having also sustained a laceration to her head, thereafter was to exsanguinate without re-gaining consciousness.
By reason of the time at which death could be established, it was determined that accepted suboptimal elements in the assessment, quality of questions asked of people contacting the police and emergency services and the resulting information gathering fell below the standard expected and applied as part of the ‘Right Care, Right Person’ response policy, this did not have any bearing upon the outcome.
Copies Sent To
Greater Manchester Fire And Rescue Service North West Ambulance Service
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.