Dear Mr Merchant,

Thank you for your report dated 27th May 2025 in respect of the death of Mr Paul Alexander.

I am aware that you will share my response with Mr Alexander’s family, and I firstly wish to express my sincere condolences to them.

Having carefully considered your report, I have prepared a response below aligned to the four areas of concern raised:

1. In the course of the evidence, it became apparent the police had introduced RCRP in September 2023. RCRP is a police initiative arising out of a national agreement but to be implemented by individual police forces. Little or no consultation with other agencies had taken place prior to the implementation of RCRP in September 2023.

2. Whilst I heard evidence that meetings with other agencies now do take place, the specifics of Paul’s case and the broader issues it raises have not been discussed nor is there any understanding/ agreement in place as to how such a situation would now be addressed.

3. As much as the court was advised was that if a similar situation arose today, there may be a discussion between operational managers in the respective police and ambulance call centres, but that this would be reliant upon the matter being brought to the attention of those respective managers by the call taker.

4. The evidence from the RCRP lead at the ambulance service indicated the scenario that arose with Paul was not an isolated example. As such there appears to be a lacuna in how emergency services will respond to such a situation when it was accepted this was a call expressing concern for Paul’s welfare.

In providing this response I have consulted with Professional Standards Directorate (PSD), Force Contact Centre, Right Care Right Person (RCRP) implementation leads and our force Mental Health lead. Furthermore, WYP have consulted with National Police Chiefs Council RCRP Project Team, Chief Inspector . 1 Background
1.1.1 Right Care, Right Person (RCRP) is an approach designed to ensure that people of all ages, who have 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.
1.1.2 RCRP is an approach developed originally by Humberside Police and partners. It sets out the principles around a partnership approach which aims to ensure that individuals in mental health crisis are responded to by the right professional.

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1.1.3 In July 2023, the Department of Health and Social Care (DHSC) launched the National Partnership Agreement (NPA): Right Care Right Person. The NPA was signed by Government, the National Police Chiefs Council, the Association of Police and Crime Commissioners the College of Policing and NHS England.
1.1.4 The RCRP approach is being implemented in West Yorkshire in four phases.
• Phase 1 relates to ‘concern for welfare’ calls;
• Phase 2 focusses on ‘AWOL’ and ‘walk out of health care facilities’;
• Phase 3 deals with transportation of patients; and
• Phase 4 concerns the use of powers under sections 136 & 135 of the Mental Health Act 1983 (MHA 1983) and voluntary mental health patients.
1.1.5 The first two phases of RCRP were launched in West Yorkshire on 4th September 2023. The latter phases were launched on 19th May 2025. 2 Consultation

In the course of the evidence, it became apparent the police had introduced RCRP in September 2023. RCRP is a police initiative arising out of a national agreement but to be implemented by individual police forces. Little or no consultation with other agencies had taken place prior to the implementation of RCRP in September 2023.
2.1.1 Whilst RCRP was launched in West Yorkshire in September 2023, WYP had been working to, what in practice, are the principles of Right Care Right Person since April 2019. This was done at the time with the full cooperation of Integrated Care Boards (ICB) and as such the Right Care Right Person changes were not anticipated to impact upon the health partners as significantly in West Yorkshire.
2.1.2 An accompanying ‘Welfare Checks Deployment Procedure’ policy was implemented and was published on WYP website - Welfare Checks Deployment Procedure - Force Policy | West Yorkshire Police
2.1.3 The above policy was discussed with partnership colleagues including Yorkshire Ambulance Service (YAS), it was revised in September 2022 after WYP and YAS jointly approved the policy and its contents. Amongst those consulted at YAS was James Goulding who provided evidence at this inquest.
2.1.4 Productive and supportive relationships were already in place in West Yorkshire, both at a strategic level and tactical level across our 5 Districts who deliver our frontline policing.
2.1.5 In effect, RCRP represented a re-launch of existing policy and practice both internally and externally to adopt a partnership approach in line with the NPA. The implementation has followed the guidance included in the College of Policing Right Care, Right Person toolkit - Right Care Right Person toolkit | College of Policing and is based on independent legal advice from . WYP had also obtained legal advice from ahead of launching the Welfare Checks Deployment Procedure.
2.1.6 RCRP was briefed to this effect, into the inaugural meeting of the Criminal Justice Mental Health Forum on 26th April 2023 and has remained as a standing item since. This followed communication from the Home Office to all police forces advocating the RCRP approach.
2.1.7 On 17th May 2023 the minutes of the meeting were circulated to the membership along with a document identifying organisations and individuals who were members of the forum. YAS were included on this document and their representative included in the circulation.
2.1.8 On 7th June 2023 the second Criminal Justice Mental Health Forum (CJMHF) was held. Representatives from across the partnership were present including West Yorkshire Police and YAS. A further update was provided on RCRP.

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2.1.9 Prior to the launch of RCRP, WYP had been engaged in discussions with YAS on establishing a joint operating model for mental health response vehicles, an initiative which directly referenced and was delivered to support the RCRP approach. (August 2023). Representatives from YAS attended some initial training sessions WYP delivered to Contact Centre staff.
2.1.10 The WYP Senior Responsible Officer (SRO) wrote to Executive leads of each Trust (September 2023) to brief them on the above.
2.1.11 A RCRP Communication subgroup was established (October 2023) and SROs were appointed in each partner agency, coordinated by WYCA (October 2023). A joint communications strategy was agreed between partner agencies aligned to RCRP (November 2023).
2.1.12 Updates on the implementation of RCRP have been reported into Community Outcomes Meetings, chaired by the Deputy Mayor for Policing and Crime since September 2023.
2.1.13 WYP have collaborated with partner agencies to deliver joint-agency RCRP training days and workshops to hundreds of people across the partnership at different levels. Several of these have been delivered in collaboration with colleagues from YAS and Social Care including two large events hosted by WYP on 12th and 26th April 2024.
2.1.14 Further events have included urgent and emergency care partners through to third sector colleagues.
2.1.15 The launch of Phases 3 and 4 of RCRP again continues partnership-led work around the transportation of mental health patients, use of Section 135 and Section 136 of the Mental Health Act 1983 and voluntary patients. Existing governance has been strengthened in the context of RCRP and opportunities to improve have been identified and developed. Two pilot initiatives are under way in collaboration with partner agencies – a community-based mental health assessment initiative and a Webley Handover initiative. Both have been communicated with partner agencies and will be comprehensively evaluated before being adopted into ‘business as usual’.
2.1.16 It is therefore our position that WYP engaged comprehensively with partner agencies ahead of the launch of RCRP and that our procedures remained consistent with existing practice which had been discussed and approved by partner agency colleagues. RCRP enabled a re-launch of our partnership approach to responding to mental health crisis in communities. It has enabled service improvements including early decision making, improved partnership communication and collaboration and continuous improvement from shared learning. 3 Shared learning to address gaps in service

Whilst I heard evidence that meetings with other agencies now do take place, the specifics of Paul’s case and the broader issues it raises have not been discussed nor is there any understanding/ agreement in place as to how such a situation would now be addressed.
3.1.1 As detailed above, the Criminal Justice Mental Health (CJMH) meeting has been developed with the support of WYCA to act as the central governance meeting for RCRP
3.1.2 Several RCRP sub-groups have been developed from learning identified from incidents and partnership discussions which include:
• RCRP Data subgroup – to share partnership data to understand service delivery across the system
• RCRP Communications subgroup – to promote shared understanding of RCRP, impact on service delivery and to quickly initiate joint communication across partners delivering RCRP
3.1.3 Previous coronial inquests have been discussed in the meeting to communicate key issues arising and develop a partnership strategy to address concerns.

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3.1.4 WYP and YAS met following these inquests and followed with joint workshops involving our contact centre to understand how each service assesses concern for welfare incidents. Location of the patient and our escalation process were discussed, both of which have continued to be developed to address learning from these inquests. We are meeting with YAS for a joint agency workshop based on the circumstances of this case and wider learning on 25th July 2025.
3.1.5 WYP and YAS have also collaborated following an inquest to review our joint procedures around hospital and healthcare walkouts. This has led to the development of joint policies and procedures with partners in the West Yorkshire Association of Acute Trusts (WYAAT)
3.1.6 As detailed further in the ‘escalation’ section below, the health system is navigating significant challenges including increased demand, complexity, lack of resources and system-wide changes. RCRP has improved our understanding and identification of these gaps, many of which were not apparent prior to implementation. A number of these gaps are system wide and are further complicated by multiple trusts and organisations working within the West Yorkshire region within different ICBs.
3.1.7 Implementing RCRP has facilitated more holistic discussions around these gaps and has enabled WYP to refine policies and procedures in line with these wider system challenges. The improved data and information sharing has enabled gaps to be identified and where possible closed. However, in many cases these gaps in service can only be mitigated, for example the availability of out of hours support for mental health crisis.
3.1.8 Under RCRP, several internal review processes have been improved and streamlined to enable rapid learning to take place.
3.1.9 WYP Professional Standards Department review every death or serious injury (DSI) following police contact.
• Identifies any operational or safety-critical issues in respect of procedures, training or equipment used; and
• Ensures individual, team and organisational learning takes place and is addressed locally and nationally, as appropriate.
3.1.10 A specific procedure has been designed with the support of WYP Professional Standards to facilitate the early triage of RCRP DSI cases to consider this: RCRP DSI process:

• The PSD Reviewing Officer forwards a summary of the incident to the WYP RCRP mailbox which is monitored by the implementation team.
• An initial triage is made on the incident and police response, assessed against force policy. A response is provided to PSD on whether the response met the requirements of force policy.
• Based on this the force may instigate misconduct proceedings. PSD also forward any 28A Learning Recommendations from the IOPC following their review of cases referred to them.
• Immediate safety or policy implications are identified and addressed at this stage, but in line with protecting the integrity of any misconduct investigation.
• Learning from such cases is (and has been previously) shared with internal staff through force messages, operational briefings, via senior leadership teams, via Contact Centre Focus Group contacts and in the meetings discussed above.
• This learning is and has been shared with partner agencies in the above meetings, but also in specific meetings and workshops organised at the appropriate time following the incident.
3.1.11 RCRP is discussed in a number of internal and external meetings and forums:

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• Mental Health Improvement Meeting – develops a place-based/local approach to partnership working.
• RCRP Focus Group Meeting – regular meeting with WYP Contact Centre teams to review incidents and developments, share learning and enable feedback.
• Tri-Service Collaboration (Police/Fire/Ambulance) – a strategic meeting for blue light services to discuss wider system pressures. RCRP has been discussed consistently since November 2023 and discussions have taken place between WYP and YAS Head of Partnerships to build joint working and collaboration between services. As part of this collaboration a Memorandum of Understanding was developed for concern for welfare incidents where West Yorkshire Fire Service can provide support with gaining entry to properties. This is a key piece of partnership working between agencies which has developed from a pilot to “business as usual” since RCRP has been launched.
3.1.12 Learning from incidents, inquests and communication with partner agencies has enabled several improvements to be made to WYP internal processes and procedures:
• Introduction of an RCRP toolkit to support effective decision making (June 2024)
• RCRP question set to apply a structured approach to each Concern for Safety incident (June 2024)
• Contact Focus Group established (November 2023) trained to deliver peer to peer training on RCRP - delivered updated training across Contact teams (July 2024)
• Internal escalation process updated and escalation training delivered to supervisors (February 2025)
• Discussions with YAS on their updated AQM and process for welfare checks where ‘location not known’ leading to a workshop discussion (September 2024) with YAS RCRP lead
• Discussions with YAS on updated (real-time) escalation process (April 2025)
• Toolkit updated to reflect learning on repeat callers, front page now assesses if the report is a ‘further report’ or a ‘new report’ (June 2025)
• Audit and review cycle implemented with Contact Team Leaders reviewing RCRP decisions on their own teams (October 2024)
• Bespoke performance and compliance data product created (July 2024)
• Internal Audit of RCRP completed for WYP Contact Centres (November 2024) with learning identified and actions completed to improve practice 4 Escalation process – WYP/YAS

As much as the court was advised was that if a similar situation arose today, there may be a discussion between operational managers in the respective police and ambulance call centres, but that this would be reliant upon the matter being brought to the attention of those respective managers by the call taker.
4.1.1 There has been an existing ‘Escalation Policy’ in force prior to the launch of RCRP, contained within the ‘Welfare check deployment criteria’ Policy, which was updated in consultation with YAS in August 2022.
4.1.2 This policy applied the same threshold for deployment as the subsequent ‘Right Care Right Person’ deployment threshold as West Yorkshire Police had looked at non-Policing demand prior to Humberside Police. In effect, WYP staff were being reminded of the existing escalation process as part of RCRP training from launch in September 2023.
4.1.3 The policy is referenced above and is publicly available via the WYP website. This Policy held until 30th October 2024, when it was updated to reference RCRP and the increased scope of this approach beyond welfare checks alone. The updated section now outlines three scenarios requiring the escalation procedure to be utilised:

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• The escalation procedure must be utilised if a Right Care Right Person (RCRP) decision not to attend is appealed by a partner agency.
• The matter can also be escalated to a supervisor when a member of the public insists on police attendance, following a no deployment RCRP decision.
• In the event of a disagreement between the requesting agency and police in terms of the immediacy of any risk to life or the identified policing objective that has necessitated the request being made, the matter must be subject of the escalation procedure to clarify whether police resources are deployed.
4.1.4 The circumstances of this case would give rise to the second and third points above, reflecting the further call to WYP requesting a welfare check and the signposting of the caller by YAS to WYP on the grounds that a missing person investigation should be considered.
4.1.5 This updated policy reflects discussions with partnership agencies, including a revised escalation process which was discussed with YAS in September 2024. Since this date, WYP have been in regular contact with YAS to develop and introduce an improved escalation process to streamline and widen the scope of escalation to support in cases where the RCRP threshold to deploy is not met.
4.1.6 Processes, procedures and terms of reference have been designed and have been approved by the Call Handling lead for YAS following consultation.
4.1.7 Every escalation must be documented by WYP using a digital form, this applies a National Decision Making rationale to the situation which can therefore be communicated with blue light partners including YAS. On submission of this form, a copy is automatically forwarded to the WYP RCRP mailbox to act as an audit trail and enables a review of quality.
4.1.8 As detailed above, the WYP RCRP Toolkit has been updated to provide specific direction for contact officers and supervisors to consider formal escalation from the outset, based on repeat calls or callers re-directed from another service. The toolkit outlines the process to the call taker/supervisor to guide them through the process.
4.1.9 A training package was developed and has been delivered to contact centre supervisors and managers. Completion of this training is being monitored to ensure that all staff at this level are trained.
4.1.10 A daily escalation review now takes place, including any incidents highlighted to the RCRP team by Contact which have no form completed. Feedback is provided to staff based on the quality and extent of the escalation and shared with contact centre leadership team.
4.1.11 Every “concern for safety” incident recorded by WYP is subject to an automated question set which asks the call taker –
• Is this call reporting a concern for a person’s welfare?
• Is there a real and immediate risk to life?
• I confirm I have applied the RCRP toolkit to this call
• Copy/paste the toolkit recommendation below *and* complete a THRIVE, based on your NDM (National Decision Model) assessment of this call
4.1.12 The responses to these questions are documented on each incident log, meaning that any incidents flagged as requiring a supervisor review are queried for escalation daily.
4.1.13 A monthly partnership meeting has commenced with YAS where escalated cases are discussed to identify shared learning and ensure a feedback loop is in place. YAS also raise any incidents submitted on Datix referrals concerning police attendance/non-attendance.
4.1.14 These improvements to the escalation process are intended to bring improvements to communication between WYP and YAS and to reduce incidents where a caller is signposted between agencies for the same call.

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5 Clarify position on responding to concern for welfare incidents

The evidence from the RCRP lead at the ambulance service indicated the scenario that arose with Paul was not an isolated example. As such there appears to be a lacuna in how emergency services will respond to such a situation when it was accepted this was a call expressing concern for Paul’s welfare.
5.1.1 The National Partnership Agreement for RCRP states: “At the centre of the RCRP approach is a threshold to assist police in making decisions about when it is appropriate for them to respond to incidents, including those which relate to people with mental health needs. The threshold for a police response to a mental health-related incident is:
• to investigate a crime that has occurred or is occurring; or
• to protect people, when there is a real and immediate risk to the life of a person, or of a person being subject to or at risk of serious harm”
5.1.2 This follows independent legal advice obtained for RCRP which outlines: “The police do not generally owe a duty of care under common law to protect individuals from harm – either harm caused by themselves or others. Where the police do not act, it is unlikely that they will be held to have breached a duty of care.”
5.1.3 The police may owe a duty of care to protect persons from harm where they have either:
• assumed responsibility to care for them
• created (directly or indirectly) the risk of harm”
5.1.4 Our response to a concern for welfare incident follows the principles set out in College of Policing APP - Safe and well checks | College of Policing
5.1.5 As reflected in College of Policing guidance – “Police officers are neither trained nor equipped to carry out clinical assessments on the mental health or wellbeing of an individual (no matter how urgent the issue is) and it is not appropriate for them to fulfil the role of a healthcare professional.”
5.1.6 The above is reflected in WYP “Concern for Welfare” policy and pre-dated RCRP as discussed above.
5.1.7 An assessment is made on every such concern for welfare incident, reinforced with an automated question set on the incident log which directs the contact officer to complete the required actions. This includes the use of the RCRP toolkit which supports the officer to make structured and consistent decisions on deployment of police resources.
5.1.8 The RCRP toolkit was developed based on practice in Humberside Police and reflects our own Concern for Welfare policy, to help operational staff navigate the policy requirements. It has now been used over 40,000 times to support operational decisions and in over 95% of RCRP incidents since being launched on 16th July 2024.
5.1.9 Each incident is not only assessed to understand when a legal duty of care is owed to an individual, but also against the core role and purpose of policing.
5.1.10 As above, every “concern for safety” incident recorded by WYP is subject to an automated question set which asks the call taker –
• Is this call reporting a concern for a person’s welfare?
• Is there a real and immediate risk to life?
• I confirm I have applied the RCRP toolkit to this call
• Copy/paste the toolkit recommendation below *and* complete a THRIVE, based on your NDM (National Decision Model) assessment of this call

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5.1.11 The toolkit recommendation referred to above contains practical advice to the member of staff on what action to take based on their navigation through the toolkit. This includes advice on when and whom to signpost callers to where appropriate.
5.1.12 Where there is no legal duty of care and the incident does not meet the core purpose of policing, the caller must be informed of this decision. At this point the call taker may signpost the caller to a more appropriate agency based on their assessment of the call, following guidance from College of Policing.
5.1.13 There is specific guidance in the toolkit and Concern for Welfare policy on when to signpost to Yorkshire Ambulance Service – “The call taker must note that Yorkshire Ambulance Service (YAS) are not the appropriate service for all mental health incidents. YAS do not conduct general concern for welfare checks. Their deployment criteria is set ‘for persons in immediate need of emergency medical care.’”
5.1.14 There is further guidance on our intranet to call takers, highlighting that the Ambulance Service will only deploy an ambulance if the location of the patient is known. The location of the patient has caused challenges in some incidents, where a different definition of location has been applied by WYP and YAS.
5.1.15 In this case the location of the patient was known and recorded as such on the WYP incident log. The call to Police detailed a concern for the welfare of Mr Alexander who was at that time outside in the street as witnessed by the caller. Furthermore, the location he was observed was outside his home address. Mr Alexander was named by the caller, and a history of mental illness was disclosed. The caller requested a welfare check on Mr Alexander.
5.1.16 On this basis the caller was signposted to Yorkshire Ambulance Service, in line with 5.1.5 above.
5.1.17 Based on the further call to WYP an opportunity was missed to re-assess and escalate our assessment with YAS using the escalation process in place at the time. This escalation process has since been reviewed to capture all incidents where there is a disagreement on which service should attend, the process is outlined from 4.1.1 above.
5.1.18 As discussed above, the RCRP deployment threshold did not change existing processes in West Yorkshire. These processes were communicated with partner agencies ahead of the implementation of RCRP, including Yorkshire Ambulance Service who were directly involved in the updated Welfare Check Procedures signed off in 2022.
5.1.19 A joint evaluation of RCRP was carried out by the Home Office and Department of Health and Social Care in December 20241 which outlines some of the unintended consequences, risks and learning identified by stakeholders. This includes the following: “Decision making can be difficult for control room staff, incidents are often not clear cut, and decisions are based on information staff are provided with, which can be incomplete… Police said implementation was an iterative process where any concerns raised were considered through checkpoint reviews before each phase, and policies amended as appropriate”
5.1.20 The evaluation made the following recommendations to support the continuing implementation of RCRP across police force areas:
• multi-agency working groups meeting regularly to discuss implementation plans openly
• internal communication within organisations so everyone understands the RCRP approach and external communication with partners
• sharing of learning between partner organisations and across areas

1 https://www.gov.uk/government/publications/evaluating-the-implementation-of-right-care-right- person/right-care-right-person

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• adequate training for staff, ensuring legal responsibilities and guidelines are followed
• effective safety protocols and single points of contact to facilitate communication
• a phased implementation approach
• establishing robust and trusted escalation processes for reviewing incidents
5.1.21 WYP reviewed the evaluation and the recommendations at the time of publication, all these areas formed part of the ongoing implementation plan. As highlighted above, the escalation process has been developed following partnership discussions and incidents arising. 6 Conclusion
6.1.1 The implementation of RCRP in West Yorkshire has been delivered with partners who were briefed ahead of the formal start of RCRP in September 2023. I must reiterate the position that RCRP did not reflect any change in existing processes but allowed us to integrate and improve our approach from working more closely in partnership to improve existing.
6.1.2 We are continuing to work closely with Yorkshire Ambulance Service and wider partnership colleagues to identify and share learning, gaps in service and any issues and concerns arising to continuously improve our service delivery.
6.1.3 I am hopeful that the detail in this response demonstrates how much RCRP has developed since the tragic circumstances of this case. As was discussed in the inquest, our approach has been to better identify, understand and mitigate the risks presented from gaps in care for mental ill health. We are continuously reviewing incidents to improve our policing and partnership response aligned with the RCRP approach.
6.1.4 In conclusion I hope this response addresses the concerns that you have raised and demonstrates our commitment to delivering RCRP as a partnership approach.