Adele Blakeman
PFD Report
All Responded
Ref: 2016-0145-wp25219
All 1 response received
· Deadline: 10 Jun 2016
Coroner's Concerns (AI summary)
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.
View full coroner's concerns
The concerns noted by the Court during the course of the Inquest are as follows: The_GMP_computer_system_hinders officers ad does not afford them hrs: missing have missing probe they clarity again Missing logs grade Missing grade grade easy access to important information within the time scales they have available to them, in order for them to adequately assess situation: Concerns around the efficiency of GMPs atiquated computer system have been raised now 0n a number of occasions and have featured in several inquests
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were
Responses
Action Planned
• GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS). • Mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making. • GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017. (AI summary)
• GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS). • Mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making. • GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017. (AI summary)
View full response
Dear Ms Kearsley Re: Adele Bernadette Blakemen (deceased) Thank you for your report sent by letter dated 15th April in respect of Adele Bernadette Blakeman deceased pursuant to_Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7 , Schedule 5 of the Coroner's and Justice Act 2009. reply to your concern as follows; Extract_trom_Regulation _28 report_point 1 The GMP computer system hinders officers and does not afford them easy access to important information within the timescales they have available to them, in order for them to adequately assess situation: Concerns around the efficiency of GMP's antiquated computer system have been raised now On a number of occassions and have featured in several inquests GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS): The programme will also improve integration of components outside of these core systems, replace ageing data warehouse capabilities and moving to data centre managed externally by a reliable supplier: Also as part of this programme of work, mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making: This mobile_technology will enable frontline officers responding to calls to have direct access to GMP IT systems and the important information contain_ Given the complexity of this change programme, GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017_ Extract_from Regulation 28_repott_point 2 There is a failure to record pertinent information about an individual on the intelligence section of an individual nominal profile. There were 5 PPI logs available to officers, no crucial pertinent information from these logs had been placed in her intelligence section, officers would have had to access each of these logs individually and read through the entire entries to elicit any inforamtion which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There. was also on one mention of involving BTP should there concerns about this individual, this partnership working was lost in the midst of one PPI log: Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street; Openshaw; Manchester M1 2NS being they
Cont.d pg 2 In respect of PPI logs, it is the responsibility of the officer submitting the PPI to submit any relevant intelligence from within the report. By the end of August all supervisors from within the Public Protection Investigation Units and who are responsible for the finalisation of any vulnerable adult PPI s will be reminded that on finalisation must quality assure the PPI with ensuring that intelligence is submitted were appropriate. This will also give them the opportunity to review any warnings, in the case of Adele both a suicidal and self harm warning would have signposted the user to fact that within that record there is information pertaining to the reason for the warning: GMP do still receive information from British Transport Police. come in two formats, one of which is managed through the Force Intelligence Bureau and the other via Divisions_ From here on in the FIB will ensure that a record of the existence of both is inputted onto the nominal action board with any trigger plans_ is taking this forward and will look at ways to improve any information sharing agreement: Extract from Regulation 28_report point 3 There was & failure to esculate this call as per the escalation procedure to & divisional Inspector for a review: It is accepted that this case was not escalated to a divisional inspector as it should have been In March 2016 Chief Inspector 05718 from the Operational Communications Branch (OCB) revised the FWIN Escalation Policy the revised version is currently at the end of the consultation phase. The new FWIN Escalation Policy sets out process for both OCB staff and divisional supervisors to make informed decisions about the escalation of incidents the National Decision Model (NDM) In principle, it aims to ensure resources are deployed to deal with any incident in a timely manner based purely upon threat; risk and harm, and not based upon the existing time based escalation points as per the existing policy document: It is anticipated that the new policy will be in place by August 2016. Extract _from Regulation 28,_report_point_4 There is a lack of understanding of the role of the IMU in missing person enquiries In January 2014, appreciating the threat,_risk and harm that is constantly being managed within the OCB Chief Superintendant 15086 implemented Risk Support Team (RST) The RST is an interim measure to support the overall function of the OCB in managing threat;, harm and risk alongside the wider organisational learning that has been identified from Regulation 28 notices, IPCC recommendations and critical incidents_ The role of the RST is to support command and control by 'identifying risk and vulnerability to victims, offenders and police officers as well as other members of the public. The RST conduct background intelligence checks that are far more detailed and complex than those carried out by divisional radio operators some systems that only the RST have access to This is predominantly done by trawiing the iS queues, scrutinising all incidents regardless of grade and summary heading: Postal address: Greater Manchester Pollce, Openshaw Complex; Lawton Street, Openshaw; Manchester M11 2NS they along the They along using using
Cont.d pg 3 The RST also deal with: FWINS that have been switched, where a radio operator feels there is a requirement for enhanced checks, where there is already a greater concern of risk Incidents that require time consuming telephone enquiries Liaison with partners , especially when checks reveal that are the most suitable agency to deal: Assisting with critical incidents and some high risk MFH enquiries. Protracted enquiries to try and locate victim when we have not managed to establish contact Searching FWINs closed on G16 (vulnerability) and update the KH details with pertinent information. Merger of duplicate OPUS records Staffing on the RST consists of one supervisor and 5 teams of 2 staff; all of whom foliow the command and control shift pattern, covering from 0700 to 0200/0300. In light of this regulation 28, the role of the Information Management Unit has been highlighted throughtout the OCB via inclusion on Divisional Orders on 27th 2016 , This highlights their role in the triage of MFH incidents amongst their other duties_ Aditionally in May 2016, Professional Standards Branch chaired organisational learning meeting with OCB, Public Protection Division and the Force Missing From Home Manager: It is proposed that we will be able to report back to the Coroners in July 2016 in terms of the wider work completed around vulnerability, including the lessons learnt from this case.
Cont.d pg 2 In respect of PPI logs, it is the responsibility of the officer submitting the PPI to submit any relevant intelligence from within the report. By the end of August all supervisors from within the Public Protection Investigation Units and who are responsible for the finalisation of any vulnerable adult PPI s will be reminded that on finalisation must quality assure the PPI with ensuring that intelligence is submitted were appropriate. This will also give them the opportunity to review any warnings, in the case of Adele both a suicidal and self harm warning would have signposted the user to fact that within that record there is information pertaining to the reason for the warning: GMP do still receive information from British Transport Police. come in two formats, one of which is managed through the Force Intelligence Bureau and the other via Divisions_ From here on in the FIB will ensure that a record of the existence of both is inputted onto the nominal action board with any trigger plans_ is taking this forward and will look at ways to improve any information sharing agreement: Extract from Regulation 28_report point 3 There was & failure to esculate this call as per the escalation procedure to & divisional Inspector for a review: It is accepted that this case was not escalated to a divisional inspector as it should have been In March 2016 Chief Inspector 05718 from the Operational Communications Branch (OCB) revised the FWIN Escalation Policy the revised version is currently at the end of the consultation phase. The new FWIN Escalation Policy sets out process for both OCB staff and divisional supervisors to make informed decisions about the escalation of incidents the National Decision Model (NDM) In principle, it aims to ensure resources are deployed to deal with any incident in a timely manner based purely upon threat; risk and harm, and not based upon the existing time based escalation points as per the existing policy document: It is anticipated that the new policy will be in place by August 2016. Extract _from Regulation 28,_report_point_4 There is a lack of understanding of the role of the IMU in missing person enquiries In January 2014, appreciating the threat,_risk and harm that is constantly being managed within the OCB Chief Superintendant 15086 implemented Risk Support Team (RST) The RST is an interim measure to support the overall function of the OCB in managing threat;, harm and risk alongside the wider organisational learning that has been identified from Regulation 28 notices, IPCC recommendations and critical incidents_ The role of the RST is to support command and control by 'identifying risk and vulnerability to victims, offenders and police officers as well as other members of the public. The RST conduct background intelligence checks that are far more detailed and complex than those carried out by divisional radio operators some systems that only the RST have access to This is predominantly done by trawiing the iS queues, scrutinising all incidents regardless of grade and summary heading: Postal address: Greater Manchester Pollce, Openshaw Complex; Lawton Street, Openshaw; Manchester M11 2NS they along the They along using using
Cont.d pg 3 The RST also deal with: FWINS that have been switched, where a radio operator feels there is a requirement for enhanced checks, where there is already a greater concern of risk Incidents that require time consuming telephone enquiries Liaison with partners , especially when checks reveal that are the most suitable agency to deal: Assisting with critical incidents and some high risk MFH enquiries. Protracted enquiries to try and locate victim when we have not managed to establish contact Searching FWINs closed on G16 (vulnerability) and update the KH details with pertinent information. Merger of duplicate OPUS records Staffing on the RST consists of one supervisor and 5 teams of 2 staff; all of whom foliow the command and control shift pattern, covering from 0700 to 0200/0300. In light of this regulation 28, the role of the Information Management Unit has been highlighted throughtout the OCB via inclusion on Divisional Orders on 27th 2016 , This highlights their role in the triage of MFH incidents amongst their other duties_ Aditionally in May 2016, Professional Standards Branch chaired organisational learning meeting with OCB, Public Protection Division and the Force Missing From Home Manager: It is proposed that we will be able to report back to the Coroners in July 2016 in terms of the wider work completed around vulnerability, including the lessons learnt from this case.
Sent To
- Greater Manchester Police
Response Status
Linked responses
1 of 1
56-Day Deadline
10 Jun 2016
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 the 29th March 2016 I concluded the Inquest into the death of Adele Bakeman date ofbirth 23rd August 1978 who died on the 28th September 2015 at Gateley Railway Station The cause of death was Multiple Traumatic Injuries: [ recorded a conclusion that the deceased had taken her own life. CIRCUMSTANCES OF THE DEATH The Court heard evidence that the deceased had history of mental health difficulties and had a multiple diagnosis of delusional disorder; social anxiety, depression, standing passivelavoidant and emotionally unstable personality traits and alcohol misuse. At the time of her death she was living at home; recently separated from her husband and was under the care of Stockport Early Intervention Team She was receiving support from her Community Psychiatric Nurse (CPN) Adele also had history of self-harming behaviour and had come to the attention of Greater Manchester Police on several occasions due to this behaviour_ On the 28th September 2015 her CPN contacted the police after he attended at Adeles home and her behaviour caused him concern He had contacted her Mother asking her to retur to the property $0 that Adele was not alone at which Adele had walked out of the house stating stthat'$ my window of opportunity gone." Her CPN had followed her & short distance but felt he was exacerbating the situation so contacted the police believing may find Adele and she_would then be assessed_for_admission to hospital. The first call to the 1a) long had point they police was at 13.44 At the Inquest the Court heard evidence from the Call Handler who received the Call from the CPN, the Radio Operator and the Assistant Radio OperatorIn addition evidence was taken from the Force Manager for Missing Persons and the Chief Superintendent of the OCB provided evidence: Evidence was heard from the above witnesses aS to the way in which the call from the CPN was coded ie as a concern for welfare or a8 a person and also as to the grading of the call. The Court found from the evidence that the initial grading of the call as a Grade 2 response was the correct grading However police call handlers to be aware that individuals telephoning into the police will not necessarily be familiar or aware of the different requirements GMP consider to label a call a8 a concern for welfare Or person: There has to be some onus on the call handlers to caller and to explain to them the reasons why need of information: The CPN was clearly providing information to GMP that he had concerns Adele was going to try and harm herself; it was the Courts view that message almost became lost to GMP: The call was then switched to the Radio Operators. It was accepted by the Asst radio operator that by 14.08 having spoken to the CPN and to Adele herself this call should have been classed as Person and not & concern for welfare. It was also accepted that the PPI should have been accessed and considered and ifhe had done $0 this call would have been a response. The Force Manager for Persons explained to the Court what happens when a missing person enquiry is transferred to the MMU. The Court was of the view that this is an important step in any missing person investigation and the MMU is much more than simply circulating someones details on the Police National Computer: This was not the understanding of other officers and was & concern to the Court. Due to a lack of resources available the call was not allocated in a timely manner and more importantly there was no escalation of the call through the escalation process: The call was not escalated to Divisional Inspector to allocate resources to There was no reason why this had not happened An officer who was allocated was then diverted to a 1 call although when she attended she was clearly of the opinion that the matter she had been diverted to was not in fact an incident which required response and the enquiry into Adele should have taken precedence: CORONER' S CONCERNS The concerns noted by the Court during the course of the Inquest are as follows: The_GMP_computer_system_hinders officers ad does not afford them hrs: missing have missing probe they clarity again Missing logs grade Missing grade grade easy access to important information within the time scales they have available to them, in order for them to adequately assess situation: Concerns around the efficiency of GMPs atiquated computer system have been raised now 0n a number of occasions and have featured in several inquests
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were PPI available to Officers no crucial pertinent information had been placed on her intelligence section officers would have had to access each of these logs individually and read through the entire entries to elicit any information which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There was also on one mention of involving BTP should there be concerns about this individual, this partnership working was lost in the midst of one PPI
3. There was a failure to escalate this call as per the escalation procedure to a divisional Inspector for a review There is a lack of 'understanding of the role of the MMU in person enquiries ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action. YOUR RESPONSE You are under & to respond to this report within 56 days of the date of this report; namely by the (0t JuZlbI; the coroner; may extend the period Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise You must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Blakeman: Lam also under a to send the Chief Coroner a copy ofyour response The Chief Coroner may publish either or both in a complete O redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest_You may make representations to methe logs from these logs Log: missing duty duty coroner; at the time of your response, about the release Or the publication of your response by the Chief Coroner_ 15.04.2016 Jeanne Kearsley Area Coroner (Vou])
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were PPI available to Officers no crucial pertinent information had been placed on her intelligence section officers would have had to access each of these logs individually and read through the entire entries to elicit any information which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There was also on one mention of involving BTP should there be concerns about this individual, this partnership working was lost in the midst of one PPI
3. There was a failure to escalate this call as per the escalation procedure to a divisional Inspector for a review There is a lack of 'understanding of the role of the MMU in person enquiries ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action. YOUR RESPONSE You are under & to respond to this report within 56 days of the date of this report; namely by the (0t JuZlbI; the coroner; may extend the period Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise You must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Blakeman: Lam also under a to send the Chief Coroner a copy ofyour response The Chief Coroner may publish either or both in a complete O redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest_You may make representations to methe logs from these logs Log: missing duty duty coroner; at the time of your response, about the release Or the publication of your response by the Chief Coroner_ 15.04.2016 Jeanne Kearsley Area Coroner (Vou])
Circumstances of the Death
The Court heard evidence that the deceased had history of mental health difficulties and had a multiple diagnosis of delusional disorder; social anxiety, depression, standing passivelavoidant and emotionally unstable personality traits and alcohol misuse. At the time of her death she was living at home; recently separated from her husband and was under the care of Stockport Early Intervention Team She was receiving support from her Community Psychiatric Nurse (CPN) Adele also had history of self-harming behaviour and had come to the attention of Greater Manchester Police on several occasions due to this behaviour_ On the 28th September 2015 her CPN contacted the police after he attended at Adeles home and her behaviour caused him concern He had contacted her Mother asking her to retur to the property $0 that Adele was not alone at which Adele had walked out of the house stating stthat'$ my window of opportunity gone." Her CPN had followed her & short distance but felt he was exacerbating the situation so contacted the police believing may find Adele and she_would then be assessed_for_admission to hospital. The first call to the 1a) long had point they police was at 13.44 At the Inquest the Court heard evidence from the Call Handler who received the Call from the CPN, the Radio Operator and the Assistant Radio OperatorIn addition evidence was taken from the Force Manager for Missing Persons and the Chief Superintendent of the OCB provided evidence: Evidence was heard from the above witnesses aS to the way in which the call from the CPN was coded ie as a concern for welfare or a8 a person and also as to the grading of the call. The Court found from the evidence that the initial grading of the call as a Grade 2 response was the correct grading However police call handlers to be aware that individuals telephoning into the police will not necessarily be familiar or aware of the different requirements GMP consider to label a call a8 a concern for welfare Or person: There has to be some onus on the call handlers to caller and to explain to them the reasons why need of information: The CPN was clearly providing information to GMP that he had concerns Adele was going to try and harm herself; it was the Courts view that message almost became lost to GMP: The call was then switched to the Radio Operators. It was accepted by the Asst radio operator that by 14.08 having spoken to the CPN and to Adele herself this call should have been classed as Person and not & concern for welfare. It was also accepted that the PPI should have been accessed and considered and ifhe had done $0 this call would have been a response. The Force Manager for Persons explained to the Court what happens when a missing person enquiry is transferred to the MMU. The Court was of the view that this is an important step in any missing person investigation and the MMU is much more than simply circulating someones details on the Police National Computer: This was not the understanding of other officers and was & concern to the Court. Due to a lack of resources available the call was not allocated in a timely manner and more importantly there was no escalation of the call through the escalation process: The call was not escalated to Divisional Inspector to allocate resources to There was no reason why this had not happened An officer who was allocated was then diverted to a 1 call although when she attended she was clearly of the opinion that the matter she had been diverted to was not in fact an incident which required response and the enquiry into Adele should have taken precedence:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action.
Inquest Conclusion
The_GMP_computer_system_hinders officers ad does not afford them hrs: missing have missing probe they clarity again Missing logs grade Missing grade grade easy access to important information within the time scales they have available to them, in order for them to adequately assess situation: Concerns around the efficiency of GMPs atiquated computer system have been raised now 0n a number of occasions and have featured in several inquests
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were PPI available to Officers no crucial pertinent information had been placed on her intelligence section officers would have had to access each of these logs individually and read through the entire entries to elicit any information which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There was also on one mention of involving BTP should there be concerns about this individual, this partnership working was lost in the midst of one PPI
3. There was a failure to escalate this call as per the escalation procedure to a divisional Inspector for a review There is a lack of 'understanding of the role of the MMU in person enquiries ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action. YOUR RESPONSE You are under & to respond to this report within 56 days of the date of this report; namely by the (0t JuZlbI; the coroner; may extend the period Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise You must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Blakeman: Lam also under a to send the Chief Coroner a copy ofyour response The Chief Coroner may publish either or both in a complete O redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest_You may make representations to methe logs from these logs Log: missing duty duty coroner; at the time of your response, about the release Or the publication of your response by the Chief Coroner_ 15.04.2016 Jeanne Kearsley Area Coroner (Vou])
2. There is a failure by officers to record pertinent information about & individual on the intelligence section of an individuals nominal profile; There were PPI available to Officers no crucial pertinent information had been placed on her intelligence section officers would have had to access each of these logs individually and read through the entire entries to elicit any information which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There was also on one mention of involving BTP should there be concerns about this individual, this partnership working was lost in the midst of one PPI
3. There was a failure to escalate this call as per the escalation procedure to a divisional Inspector for a review There is a lack of 'understanding of the role of the MMU in person enquiries ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and [ believe you have the power to take such action. YOUR RESPONSE You are under & to respond to this report within 56 days of the date of this report; namely by the (0t JuZlbI; the coroner; may extend the period Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise You must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, the family of Mrs Blakeman: Lam also under a to send the Chief Coroner a copy ofyour response The Chief Coroner may publish either or both in a complete O redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest_You may make representations to methe logs from these logs Log: missing duty duty coroner; at the time of your response, about the release Or the publication of your response by the Chief Coroner_ 15.04.2016 Jeanne Kearsley Area Coroner (Vou])
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.