Coroner's Concerns (AI summary)
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act on heat source information, contributing to an unorganised and uncoordinated search. The family were incorrectly told that no heat sources had been identified.
View full coroner's concerns
This document was classified as: OFFICIAL There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around Summerhill Park had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around Summerhill Park had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
Responses
Action Taken
• Staff were reminded to undertake a risk assessment when undertaking medication reviews. • Risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. • Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment. (AI summary)
• Staff were reminded to undertake a risk assessment when undertaking medication reviews. • Risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. • Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment. (AI summary)
View full response
Dear Madam
I write following conclusion of the Inquest touching the death of Grant Lowry. Following the Inquest, you asked the Trust to confirm "that staff are reminded to undertake a risk assessment when undertaking medication reviews". To provide further assurance regarding risk assessment processes following clinical reviews, it is important to note that risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment. During patient consultations, it is expected that risks are reviewed in accordance with the individual's presentation, mood, and sleep patterns, and that direct questions are posed in relation to self-harm and suicidal ideation. In addition to risks to self, whether intentional or unintentional, clinicians are required to review risks from others, risks to others, forensic risks, risks arising from the service itself (including iatrogenic harm), safeguarding concerns, and risks relating to physical health, among any other relevant risk factors. Community Modern Matron Stockton & Hartlepool AMH Planned Care Marton Road, Middlesborough Cleaveland TS4 3AF
In Grant's case a call was made to Grant's mother by a trainee nursing associate, has previously agreed, to discuss Grant's medication. Where contact is made with carers, their views are sought in accordance with the domains set out within the safety summary (risk assessment). In circumstances where information is being obtained from carers, it is expected that a general discussion is undertaken regarding any changes in presentation that may have an impact upon the individual's risks. Following the Inquest this matter has been escalated through the Quality Standards Group, which is chaired by the Associate Directors of Nursing and attended by Team Managers, Matrons, and Clinical Specialists. A formal discussion was held at the Quality Standards meeting on 8th April 2026 to address this information, with a request that the findings be cascaded to clinical teams accordingly. I can confirm that, following GL's death, changes have been made to the electronic care recording system currently in place. The system now incorporates an automatic prompt requiring clinicians to confirm whether a risk assessment has been reviewed when completing a clinical entry; where it has not, a documented rationale must be provided. The electronic system is configured such that a clinician is unable to save a clinical entry without either confirming that an individual's risks have been reviewed or providing an explanation as to why this was not possible. Where risks have not been reviewed directly with the patient, for example in circumstances where contact was made solely with a carer, this would be recorded as the rationale upon saving the clinical entry. I hope you are assured that learning arising from the Inquest has been acted upon and discuss with clinical teams. We reiterate our sincere condolences to Grant's family.
I write following conclusion of the Inquest touching the death of Grant Lowry. Following the Inquest, you asked the Trust to confirm "that staff are reminded to undertake a risk assessment when undertaking medication reviews". To provide further assurance regarding risk assessment processes following clinical reviews, it is important to note that risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment. During patient consultations, it is expected that risks are reviewed in accordance with the individual's presentation, mood, and sleep patterns, and that direct questions are posed in relation to self-harm and suicidal ideation. In addition to risks to self, whether intentional or unintentional, clinicians are required to review risks from others, risks to others, forensic risks, risks arising from the service itself (including iatrogenic harm), safeguarding concerns, and risks relating to physical health, among any other relevant risk factors. Community Modern Matron Stockton & Hartlepool AMH Planned Care Marton Road, Middlesborough Cleaveland TS4 3AF
In Grant's case a call was made to Grant's mother by a trainee nursing associate, has previously agreed, to discuss Grant's medication. Where contact is made with carers, their views are sought in accordance with the domains set out within the safety summary (risk assessment). In circumstances where information is being obtained from carers, it is expected that a general discussion is undertaken regarding any changes in presentation that may have an impact upon the individual's risks. Following the Inquest this matter has been escalated through the Quality Standards Group, which is chaired by the Associate Directors of Nursing and attended by Team Managers, Matrons, and Clinical Specialists. A formal discussion was held at the Quality Standards meeting on 8th April 2026 to address this information, with a request that the findings be cascaded to clinical teams accordingly. I can confirm that, following GL's death, changes have been made to the electronic care recording system currently in place. The system now incorporates an automatic prompt requiring clinicians to confirm whether a risk assessment has been reviewed when completing a clinical entry; where it has not, a documented rationale must be provided. The electronic system is configured such that a clinician is unable to save a clinical entry without either confirming that an individual's risks have been reviewed or providing an explanation as to why this was not possible. Where risks have not been reviewed directly with the patient, for example in circumstances where contact was made solely with a carer, this would be recorded as the rationale upon saving the clinical entry. I hope you are assured that learning arising from the Inquest has been acted upon and discuss with clinical teams. We reiterate our sincere condolences to Grant's family.
Sent To
- Cleveland Police
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 06 June 2022 I commenced an investigation into the death of Grant Nicholas LOWRY aged
20. The investigation concluded at the end of the inquest on 26 March 2026. The jury made the following determinations:
Grant had a diagnosis of ADHD, Anxiety and Depression which contributed to the circumstances surrounding his death. Non prescription drugs may have also contributed and affected his behaviour. He was known to mental health services where there were missed opportunities to provide further input into Grant's mental health. He left the family home 01.06.2022 in good spirits with his bag giving no cause for concern. Subsequently this changed when his mother received a worrying text message and alerted the Police. This led to an unsatisfactory and uncoordinated search with missed opportunities and incomplete records that delayed the discovery Grant. Grant hanged himself from a tree branch using a slip dog lead on an area of woodland at Brierton Lane and was found on 03.06.2022.
The conclusion of the inquest was: Suicide whilst the balance of his mind was disturbed, in the context of a mental illness.
20. The investigation concluded at the end of the inquest on 26 March 2026. The jury made the following determinations:
Grant had a diagnosis of ADHD, Anxiety and Depression which contributed to the circumstances surrounding his death. Non prescription drugs may have also contributed and affected his behaviour. He was known to mental health services where there were missed opportunities to provide further input into Grant's mental health. He left the family home 01.06.2022 in good spirits with his bag giving no cause for concern. Subsequently this changed when his mother received a worrying text message and alerted the Police. This led to an unsatisfactory and uncoordinated search with missed opportunities and incomplete records that delayed the discovery Grant. Grant hanged himself from a tree branch using a slip dog lead on an area of woodland at Brierton Lane and was found on 03.06.2022.
The conclusion of the inquest was: Suicide whilst the balance of his mind was disturbed, in the context of a mental illness.
Circumstances of the Death
Grant left his family home in the evening of 01.06.22 saying he was going to Summerhill Park in Hartlepool. Approximately forty minutes later he sent his mum a text message which indicated suicidal intent. His mother reported this to the police. The Police attended Summerhill Park and arranged for NPAS to attend. NPAS identified two heat sources, both of which were relayed to the police before leaving. NPAS directed officers to the first heat source. The Officer was unable to reach the heat source. The heat source was not recorded accurately nor was the officer’s inability to reach the heat source. The second heat source was not heeded, was not recorded and was not searched. The Police were unable to contact their own POLSA. At around midday on 02.06.22 the police contacted mountain rescue, arranged their own dogs to attend and requested POLSA via mutual aid. Grant was located deceased by a dog walker in the early hours of 03.06.22.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.