UK Inquiry Tracker

Donna Smith

PFD Report All Responded Ref: 2024-0264

Date of Report 8 May 2024

Coroner David Reid

Coroner Area Worcestershire

Response Deadline ✓ from report 3 July 2024

Alcohol, drug and medication related deaths

Judiciary.uk Report PDF

All 2 responses received · Deadline: 3 Jul 2024

Coroner's Concerns (AI summary)

A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.

View full coroner's concerns

(1) I heard evidence at the inquest that there was at the time of these events, and there remains now, a complete lack of formalised written policies, procedures or guidance governing the relationship between those operating CCTV cameras in Worcestershire ( as Wychavon District Council do in respect of Worcester city centre CCTV cameras ) and West Mercia Police; (2) At the inquest I found as a matter of fact that the failure by either the CCTV operator or the police communications officer to call th~ ambulance service immediately after their call over Airwaves, and their lack of understanding over whose responsibility it was to make such a call, arose substantially because of this lack of formal written guidance; (3) Furthermore, I heard evidence that despite Ms. Smith's death having occurred over 12 months ago, a draft Memorandum of Understanding between West Mercia Police and those operating CCTV cameras in Worcestershire had not yet been completed or formalised, but rather was still "being drawn up". For all of the above reasons, I am concerned that unless action is taken to formalise the relationship between those operating CCTV cameras in Worcestershire and West Mercia Police, and to provide proper guidance setting out their respective responsibilities in situations such as this, there is a risk that other deaths may occur in the future.

Responses

West Mercia Police Police / Law Enforcement

2 Jul 2024

Action Taken
West Mercia Police has withdrawn Airwave Radio from CCTV rooms, now receiving all contact from them via telephony which automatically creates a Contact Record for triage and decision-making, addressing a communication gap. (AI summary)

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Dear Mr. Reid. Re: The Late Donna Louise Smith (Ref: 11667910) Thank you for your correspondence of 9th May 2024 accompanying the Regulation 28 Prevention of Future Deaths Report. I would like to assure you of the steps taken by West Mercia Police to address the concerns raised in your report about the potential for similar incidents to reoccur. The incident was investigated separately by the IOPC, having been referred by West Mercia Police, resulting in a recommendation that a Memorandum of Understanding (MOU) should be agreed between the Local Policing Area and Local Authority CCTV Centres. Part of the development of that MOU includes the withdrawal of Airwave Radio from CCTV rooms in recognition that this may not be the most appropriate way for them to communicate with West Mercia's Public Contact Centre. As a result of the removal of the ability for CCTV to contact the police via Airwaves, we now receive all contact from them via telephony. This allows for the automatic creation of a Contact Record on receipt of their call whereupon any decision around police attendance and the Most Appropriate Agency (MAA) Policy will follow the TRIAGE process. This will be documented on the Contact Record, as with any other call for service from the public or partners. As the incident concerning Donna Louise Smith was managed via Airwave, it did not generate a Contact Record and therefore there was no recording of the TRIAGE decision making. The revised procedure seeks to close the communication gap between CCTV operators and police to reduce the likelihood of such an incident reoccurring. It also provides for clear recording of decision- making processes, identification of clear lines of responsibility for both agencies and provides a means by which rationale for decisions made can be documented.

O @ @westmerciapolice X @WMerciaPolice

I am keen to ensure that all necessary action is taken to prevent other families from experiencing such tragic loss in similar circumstances and am assured that the procedure outlined above is robust enough to meet that aim and fully embedded within the Public Contact Centre. I do recognise that there may be a disadvantage with CCTV operators not having access to Airwave and I will keep the policy under review. Please do not hesitate to contact me if you require any further information to support your enquiries. Temporary Chief Constable

O @ @westmerciapolice X @WMerciaPolice

Wychavon District Council Local Authority / Fire Service

1 Aug 2024

Action Taken
Wychavon District Council CCTV operators will now call 999 for specified incidents, requesting a reference log/number which will create a Contact Record; no further action is expected from CCTV operators once the call is made and the Contact Record recorded. (AI summary)

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Dear Mr Reid

The Late Donna Louise Smith

Thank you for your correspondence of 9 May 2024 accompanying the Regulation 28 Prevention of Future Deaths Report and the agreement to an extension to 2 August for our response.

We had hoped to submit a joint response with West Mercia Police but we understand they are sending a separate response.

Therefore, I have considered the letter sent by Alex Murray on behalf of West Mercia on 2 July and would put forward the following as the process to be followed by Wychavon District Council CCTV operators. This process has the aim to close the gap in communication between the agencies and reduce the likelihood of a similar situation happening again. In addition, it provides a means for a formal record to be set up by using the 999 communications channel following the removal of Airwave Radio from CCTV rooms in line with Police policy.

POLICY FOR WYCHAVON CCTV OPERATIVES

When an incident is picked up on CCTV, the operative will call 999 and

- if it is a visible medical emergency will request the ambulance service attend and request a reference log/number.

- if a fire emergency request the fire service attend and request a reference log/number.

- if any other serious incidences a request for the police to respond. Serious incidences will include: o A serious offence is in progress or has just been committed;

o Someone is in immediate danger; o Serious disruption to the public is occurring or is likely to occur.

When contact is made with the Police a Contact Record will automatically be created. At this point the police will make a decision around police attendance and the Most Appropriate Agency Policy will be activated. The CCTV operative is to record the details of the Contact Record for future reference on the existing incident record logs.

There is no further action expected from the CCTV Control Room operatives once the call has been made and the Contact Record recorded. All other incidences will be reported via 101.

I hope this is satisfactory to you and will ensure that there is no gap in communication between agencies during such incidences in the future.

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2024-0037
Sent to: Department of Health & Social CareNorth East Ambulance Service Foundation Trust

All responded

This report (2024-0264) is shown above.

Sent To

West Mercia Police
Wychavon District Council

Response Status

Linked responses 2 of 2

56-Day Deadline 3 Jul 2024

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 5 April 2023 I commenced an investigation and opened an inquest into the death of Donna Louise SMITH ( dob 06.02.1975). The investigation concluded at the end of the inquest on 7 May 2024. The conclusion of the inquest was that Ms. Smith's death was alcohol-related.

Circumstances of the Death

In answer to the questions "when, where and how did Ms. Smith come by her death?", I recorded as follows: "On the morning of 4.3.23 Donna Smith was found unresponsive in Worcester City Centre. She was taken to Worcestershire Royal Hospital where, a short time later, she was confirmed deceased. She died as the result of acute alcohol intoxication." Ms. Smith had first been spotted on a Worcester city centre CCTV camera ( operated by an employee of Wychavon District Council ) at 0654hrs on the morning of 4.3.23, lying in a flower bed outside the Maggs Day Centre, Deansway. She remained there for the next two hours or so, at which point the CCTV operator became concerned for her wellbeing and contacted the West Mercia Police control room. In that call over Airwaves radio, the CCTV operator stated that Ms. Smith had not moved at all for several minutes and "might be subject to hypothermia". The communications officer to whom he spoke replied "that would need to go to the ambulance service", at which point the call ended. In fact, neither party made a call to the ambulance service, as each had assumed that the other would be making the call. The communications officer stated in evidence to the inquest that although she felt she was being clear at the time, she appreciated that the words she used "could have been ambiguous". In the end, a concerned member of the public found Ms. Smith, and made a call to the ambulance service some 20 minutes later. Paramedics attended, provided Advanced Life Support, and took Ms. Smith to Worcestershire Royal Hospital, where she died later that morninQ. The cause of death established at inquest was: 1a acute alcohol (ethanol) intoxication; 2 hepatic steatosis, left ventricular hypertrophy. Given the evidence which I heard at the inquest, I could not conclude, on the balance of probabilities, that a timely phone call to the ambulance service by either the CCTV operator or the police communications officer would in fact have led to a different outcome in this case.