Greater Manchester Police

PFD Addressee
Reports: 36 Earliest: Jan 2014 Latest: 15 Mar 2026

83% 2-year response rate (matches average). 46% of classified responses show concrete action taken.

PFD Reports
36 results
Ruslans Burkevics
Response Pending
2026-0175 15 Mar 2026 Manchester West
Mental Health related deaths
Concerns summary (AI summary) Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.
Roger Leadbeater
All Responded
2026-0041 23 Jan 2026 South Yorkshire West
Other related deaths
Concerns summary (AI summary) Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Action Taken (AI summary) • A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. • A mandatory task has been embedded within Compact, our MFH management system, providing officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form. • A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light.
Lewis Bates
All Responded
2025-0602 1 Dec 2025 Manchester South
Suicide
Concerns summary (AI summary) Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.
Action Planned (AI summary) GMP is undertaking a review of policies, delivering updated training to call handlers, reinforcing escalation protocols, and implementing quality assurance measures through supervisory reviews. The FCCO's in-house guidance system, Sherlock, will be updated and new training will incorporate these revisions.
Elaine Tarbuck
All Responded
2025-0342 7 Jul 2025 Manchester West
Police related deaths
Concerns summary (AI summary) The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action Planned (AI summary) GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.
Alfie Lawless
All Responded
2025-0118 4 Mar 2025 Manchester South
Police related deaths Suicide
Concerns summary (AI summary) Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.
Action Taken (AI summary) Greater Manchester Police PSD has designed a new form for assessing incidents relating to Death or Serious Injury (DSI), including rationale and learning opportunities; the PSD's Organisational Learning team will monitor the forms and escalate any risks to the Tactical Organisational Learning Board. The PSD will ensure mandatory referrals are made without delay, ensure AA's attend formal training and will undertake a period of monthly dip sampling to ensure that this process is embedded.
Sean Heath
All Responded
2024-0524 2 Oct 2024 Manchester South
Mental Health related deaths Suicide
Concerns summary (AI summary) Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.
Elizabeth McCann
All Responded
2024-0288 29 May 2024 Manchester South
Other related deaths
Concerns summary (AI summary) High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.
Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.
Ashley Crews
Partially Responded
2024-0216 23 Apr 2024 Manchester City
Other related deaths
Concerns summary (AI summary) The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.
Noted (AI summary) Greater Manchester Police acknowledges the absence of a specific policy on handcuffing during search warrant executions, but states that use of force is a case-by-case decision guided by legislation, the National Decision Model, and consideration of occupants' vulnerabilities.
Samuel Curless
All Responded
2024-0089 19 Feb 2024 Manchester South
Suicide
Concerns summary (AI summary) Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Noted (AI summary) The College of Policing updated the First Aid Learning Programme (FALP) in 2020, increasing recommended training time for both refresher and initial training for public-facing officers, now including basic life support and airway techniques. Annual refresher training is a core requirement of the FALP license. Response is a placeholder document.
Claire Briggs
All Responded
2023-0513 8 Dec 2023 Manchester South
Alcohol, drug and medication related deaths Emergency services related deaths
Concerns summary (AI summary) A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Noted (AI summary) NHS England outlines existing guidance for ambulance services relating to overdoses and suicidal intent issued in April 2021, and describes ongoing work to improve ambulance performance. North West Fire Control is supporting the embedding of Joint Emergency Services Interoperability Principles (JESIP) and working with partners to implement electronic data transfer for improved information sharing, expected by March 2024. Cheshire Constabulary has signed the Joint Operating Protocol (JOP) with NWAS and supports its endorsement by other parties, with a coordination meeting scheduled for January 16, 2024. Lancashire and South Cumbria ICB reports that four North West police forces have agreed and gone live with their Joint Operating Protocols (JOPs) with NWAS, with Greater Manchester Police in the final stages of agreement, and learning will be overseen by the NWAS Regional Clinical Quality Assurance Committee. Cumbria Constabulary has signed a regional Information Sharing Agreement (ISA) and has been working under a Joint Operating Procedure (JOP) since October 2023; it also provides clinical support through its "treat and hear" facility. Lancashire Fire and Rescue Service states that it was not involved in the incident, but is committed to improvement and learning. The service outlines its support for JESIP, reviews policies/procedures/training, and has an Immediate Emergency Care SOP with guidance on various areas. The North West Ambulance Service (NWAS) have engaged with all the North West Police Forces to develop a Joint Operating Protocol (JOP). Four forces have agreed and gone live with their JOPs, ensuring clear process for sharing information, primacy understanding, and a clear escalation process for any operational issues. Four of the North West police forces, including Cheshire Constabulary and Merseyside Police, have agreed and implemented Joint Operating Protocols (JOPs) with the North West Ambulance Service to improve information sharing and escalation processes. BTP has adopted the "Ten Second Triage" (TST) tool nationally and is delivering associated training in 2024. They also use ESICTRL radio talk groups for direct communication between emergency service control rooms. NWAS reports that a Joint Operating Protocol (JOP) has gone live with Cheshire, Cumbria, Lancashire and Merseyside Police Forces, and that an updated version has been agreed with Greater Manchester Police and is scheduled for implementation across the whole North West following a meeting in late February 2024; also, the JOP has been extended to include British Transport Police, North West Fire Control, and Fire and Rescue Services. Merseyside Fire and Rescue Service states that its existing procedures for communicating casualty information to NWAS are sufficient, including written instructions and escalation options. Response not parsable Lancashire Police has agreed to Version 1.3 of a Joint Operating Protocol (JOP) with regional forces and NWAS to provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays; awaiting final sign-off from GMP and Fire and Rescue.
Rebecca Fisher
All Responded
2023-0154 15 May 2023 Manchester South
Suicide
Concerns summary (AI summary) GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information sharing. The effectiveness of new training and tools remains unconfirmed.
Action Taken (AI summary) GMP has rolled out an Aide Memoire system, enhanced training, developed a supervisor's checklist, and conducts audits every six months to improve responses to missing persons. District performance is reviewed quarterly.
Angeline Phillips
All Responded
2022-0412Deceased 21 Dec 2022 Manchester West
Emergency services related deaths
Concerns summary (AI summary) The provided text only states that police incident response policy governs priority and response times, without detailing any specific concerns or failures related to this policy.
Action Taken (AI summary) GMP reviewed and implemented its Incident Response Policy (IRP) in Feb 2022 incorporating the THRIVE risk assessment approach. All FCC officers and staff received training on the IRP and THRIVE, supplemented by audits and briefings. The M-HUT pilot is testing processes to address mental health demand in partnership with other agencies.
Hannah Beardshaw
All Responded
2022-0111 13 Apr 2022 Manchester West
Mental Health related deaths Police related deaths Suicide
Concerns summary (AI summary) Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.
Noted (AI summary) GMP has revisited its Graded Response Policy (GRP), implementing a new GRP on 1 February 2022 using the THRIVE framework for risk assessment. They are also implementing a new IT system called 'Sherlock' by August 2022 to improve information storage and access in the FCC. The IOPC acknowledges the report and highlights its power to make organisational learning recommendations to relevant bodies. They state that GMP has a legal obligation to respond to the recommendations in writing by 20 July 2022.
Anthony Fitzpatrick
Historic (No Identified Response)
2021-0411 7 Dec 2021 Manchester South
Mental Health related deaths Police related deaths Suicide
Concerns summary (AI summary) Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.
Zeyna Partington
All Responded
2021-0181 27 May 2021 Manchester North
Police related deaths Suicide
Concerns summary (AI summary) GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.
Action Planned (AI summary) Greater Manchester Police acknowledges concerns about the use of PNC markers and ANPR data. They are reviewing the use of high priority markers for vulnerable missing persons and are working to connect to the new National ANPR Service.
Jade Rayner
All Responded
2021-0128 30 Apr 2021 Greater Manchester South
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.
Action Planned (AI summary) Two task and finish groups will review Section 42 and Multi Agency Adults at Risk System processes, with learning to be shared with the Greater Manchester Quality Board and commissioners of services. GMP has implemented the vulnerability assessment framework to identify and assess risk factors, and officers now record care plans after safe and well interviews with vulnerable adults.
Robert Hardy
All Responded
2021-0039 11 Feb 2021 Greater Manchester South
Mental Health related deaths Police related deaths Suicide
Concerns summary (AI summary) Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.
Action Taken (AI summary) Greater Manchester Police has established a central Crime Recording and Resolution Unit (CRRU) to improve crime recording accuracy, in response to concerns raised. They are also implementing the national THRIVE model and the 'Making a Difference System' to improve identification of and response to vulnerabilities and to improve victim support.
Jason Pendlebury
All Responded
2020-0069 12 Mar 2020 Manchester North
Alcohol, drug and medication related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly led to inadequate risk assessments and missed opportunities for mental health intervention.
Action Planned (AI summary) Greater Manchester Police is working towards an electronic information sharing system with NWAS to improve communication, and plans are in place to develop a training package for OCB staff including clear instructions regarding information sharing with NWAS. NWAS states that a referral process was only due to go live in 2021, but has been brought forward in light of the current COVID-19 pandemic. The current process is that NWAS Clinical Hub will identify two mental health incidents per hour from 999 or 111 that are either a Category 3 or Category 4 mental health incident.
Michael Hoolickin
All Responded
2019-0292 29 Aug 2019 Manchester (North)
Other related deaths
Concerns summary (AI summary) The coroner is reporting to prevent future serious further offence reviews following a death.
Noted (AI summary) The NPCC acknowledges the concerns and explains its role in encouraging collaboration between forces, stating that it will share the report and IOM guidance with chief constables across the country, but does not have the authority to direct action. The Probation Service acknowledges the need for learning and improvement. The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included. Response contains no text. Response contains no text.
Adam Harris
All Responded
2019-0247 23 Jul 2019 Manchester (South)
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance on prisoner positioning for aspiration risk were critical concerns.
Noted (AI summary) Greater Manchester Police explained their procedures for allocating detainee cell space and the role of the cell allocation team and Custody Inspector. They also detailed officer training and procedures for handling detainees who may be confused or intoxicated, as well as explaining when a full custody record may not be completed immediately.
Alfred Sykes
All Responded
2019-0201 18 Jun 2019 Manchester (South)
Other related deaths
Concerns summary (AI summary) The report identified unspecified matters of concern indicating a risk of future deaths.
Action Taken (AI summary) GMP will review all high-risk missing person searches daily with another officer and appraise the Force Search Coordinator. Annual PoISA/Search Manager CPD will include refresher training using incidents that have occurred within the force or nationally.
Anne-Marie Nield
All Responded
2019-0477 25 Jan 2019 Manchester (North)
Other related deaths
Concerns summary (AI summary) Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a risk factor, conducted inadequate assessments, and critical recommendations remained unimplemented.
Action Planned (AI summary) Greater Manchester Police accepts the points raised and will use this case as a study for video briefings to frontline officers, including non-fatal strangulation, VCOP, definitions, markers, flags, and escalating risk, and closing standard risk cases. They will improve the IDVA service and 'field test' practitioners knowledge.
Dane Pearson
Partially Responded
2019-0056 14 Jan 2019 Manchester (South)
Mental Health related deaths Suicide
Concerns summary (AI summary) Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.
Action Planned (AI summary) The College of Policing is updating APP on issuing CAWNs to include a risk assessment and link to existing suicide prevention guidance. Additionally, GMP has implemented activities including providing districts with information, revising the bail and RUI policy, briefing front line officers, introducing trackers and dip sampling records.
Gregory Rewkowski
All Responded
2018-0411 28 Dec 2018 Manchester (North)
Community health care and emergency services related deaths
Concerns summary (AI summary) The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the clinical lead's inaction, failure to escalate to a senior manager, restrictions on ward telephones, limited NWAS investigation, and concerns about police handling of Section 136 cases.
Action Planned (AI summary) Pennine Care NHS Trust has increased staffing levels, issued a memo to staff for greater awareness of the requirement to seek support from On-Call managers, and are planning to update policies and practice on how to respond to information in the public domain in the most effective manner. Greater Manchester Police will participate in a task and finish group and is represented at senior level on the GM Health and Justice Operational Delivery Group and the Greater Manchester Health and Justice Board, with focus on reviewing multi-agency protocols, shared resources, and formal joint working action plans. The partnership has developed a pan-GM protocol for response to mental health crisis, aiming for a common understanding of roles and responsibilities, a shared view of risk, and improved communication.
Thomas Gallagher
All Responded
2016-wp25354 11 Aug 2016 Greater Manchester (North)
Police related deaths
Concerns summary (AI summary) Staff lacked formal training in risk assessment and child mental health, and there was intentional disregard of force policies; also, decisions not to allocate additional cover or resources lacked documented rationale, and a 'Golden Hour' was missed due to delays.
Action Taken (AI summary) GMP has implemented a programme of staff training emphasizing vulnerability, safeguarding, and risk mitigation. Locally, Bury has introduced a demand/triage desk and intelligence support to conduct Golden Hour tasks, including service calls to informants. The escalation policy has been amended to require recall to the informant within 40 minutes.