Donna Constantine

PFD Report All Responded Ref: 2021-0350
Date of Report 19 October 2021
Coroner Alison Mutch
Response Deadline est. 14 December 2021
All 2 responses received · Deadline: 14 Dec 2021
Coroner's Concerns (AI summary)
Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.
View full coroner's concerns
The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.

However the phones are not monitored when officers are off duty or on annual leave. This the inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way
e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.

The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.

In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
Responses
Home Office Central Government
1 Dec 2021
Noted
The Home Office acknowledges the concerns and states that police forces are operationally independent and it is for Greater Manchester Police, the NPCC and the College of Policing to address the issues raised. (AI summary)
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Home Office ' Ms Alison Mutch Coroner's Court, 1 Mount Tabor Street 0 1 DEC 2021 HM CORONER MANCHESTER SOUTH Home Secretary 2 Marsham Street London SW1 P 4DF

Stockport SK13AG DECS Reference: MIN/0197456/21 ~ovember 2021

T{a~k you for your letter of 19 October enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Ms Donna Ann Constantine. I was saddened to learn about the death of Ms Constantine and I would first like to express my deepest condolences to her family for their loss. I acknowledge your concerns detailed in your report, and should stress that police forces are operationally independent and, as such, it is for the Greater Manchester Police, the National Police Chiefs Council and the College of Policing to address the specific issues raised about their ways of working as they relate to the inquest into the death of Ms Constantine. However, I can reassure you that the NPCC and CoP, who you have named in the report and have operational responsibilities are aware of the recommendations and are working together to address them and respond within the requisite 56-day period. As a department I can advise we will continue to liaise with the NPCC and CoP on the development of policing policy and ensure that they take forward their response to your recommendations. Additionally, I would like to assure you that the police take their duty of care towards vulnerable people very seriously and work hard to ensure appropriate and safe outcomes for the public that they serve. Improving the way in which the police respond to people who have vulnerabilities, whether they are suspected of committing a crime or not, is of utmost importance to me and we are playing our part to ensure that vulnerable people receive the treatment and care they need when they come into contact with the police. Thank you for writing to me on this important matter. I hope that my response has demonstrated that we take the duty of care of vulnerable people seriously and continue to work to make Improvements. Rt Hon Priti Patel MP
National Police Chiefs' Council Police / Law Enforcement
14 Dec 2021
Noted
The NPCC and College of Policing note the concerns and explain that the Victims Code was updated in April 2021. They state that forces are not encouraged to give out mobile phone numbers and provide guidance for officers receiving emergency calls. (AI summary)
View full response
Dear Ms Mutch Regulation 28 Report – Ms Donna Ann Constantine We write on behalf of the National Police Chiefs Council (NPCC) and the College of Policing (the College) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and the prevention of future deaths reports sent to the NPCC and the College, both dated the 19th October 2021. Whilst the NPCC and the College have separate and distinct responsibilities, the two organisations frequently work together on national approaches to policing policy. As such, this response is provided jointly in respect of both organisations’ separate prevention of future deaths reports. The notice sets out concerns that arose from the information received during the inquest into the death of Ms Constantine. We are very sorry to read of the circumstances of Ms Constantine’s death. Our sympathies are with her family and friends and we share your commitment to addressing the issues that contributed to her untimely loss. The notice sets out your principal concern which highlights a text message sent by a vulnerable person to a Police Officer’s mobile phone which was not being monitored and your concern that giving out officer’s phone numbers to victims was a national policing approach. In order to establish a better understanding of the circumstances in relation to this PFD we have met with the relevant leads from Greater Manchester Police and wider NPCC portfolios to discuss this fully.

Firstly, it is important to note that since the death of Ms Constantine, the Victims Code was updated in April 2021, with a number of key changes having been introduced. These are:
• The Code provides 12 overarching rights, so it is easier to understand and apply.
• It makes frequency and method of contact with the victim, victim led.
• Officers and staff must minimise contact points and provide a 'single points of contact' for information where possible.
• Officers and staff have more discretion as to when it is most appropriate to offer a victim personal statement.
• There is a greater emphasis on explaining 'why' certain decisions have been made The purpose of the victim’s code is to maintain contact with the victim in relation to their reported crimes, along with implementing any special measures required as a vulnerable person. It is appreciated of course that officers dealing with an investigation may wish to give their work number/email address to a victim of crime as a point of contact. This would be in order to discuss the progress of their crime or request/ gather further information as required. However, forces nationally are not (neither had they been prior to April 2021) encouraged to give out mobile phone numbers as a point of contact in an emergency or in the event of illness/concern for welfare. Should victims have an emergency they are encouraged to call 999 or 101 for a non- emergency in every case. Should an officer receive a call which indicates an emergency/concern for welfare they would be expected to call the relevant control room to report the incident which can then be recorded and allocated for attendance in the usual way. We hope that this addresses the concerns you raise. Should you have any further questions in relation to our response please send this to
Sent To
  • National Police Chiefs’ Council, Home Office, College of Policing and Victims Commissioner for England
Response Status
Linked responses 2 of 1
56-Day Deadline 14 Dec 2021
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 23rd September 2019 I commenced an investigation into the death of Donna Constantine. The investigation concluded on the 30th September 2021 and the conclusion was one of open. The medical cause of death was unascertained.
Circumstances of the Death
On 21st September 2019 Donna Ann Constantine was found at her home address after neighbours raised concerns. She was severely decomposed. Post mortem examination could not establish a cause of death due to decomposition. Donna Ann Constantine was a vulnerable adult known to multiple agencies including Mental Health Services and Greater Manchester Police. She had repeatedly expressed suicidal ideation in the past. She had taken the tenancy at from 12th August 2019. She was supported by the Housing Resettlement Worker from her temporary accommodation. She was referred to the Housing Support Service for support post her move. She sent a text message to her Housing Resettlement Worker and a Greater Manchester Police Officer whose work mobile number she had been provided with to indicate she was very unwell on 18th August 2019. She sent no text messages after 20th August 2019. Attempts to follow up dropping off her belongings were not made after 22nd August 2019. Unsuccessful attempts to contact her by the Housing Support Team were not escalated. The last known activity from her phone was on 22nd August 2019. No concerns for welfare were raised in the period from 22nd August until she was found on 21st September 2019.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.