“The police were called to the address after the first assault had occurred and were still…”

The coroner’s concerns

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— 1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the fiat and beat the deceased to his death. Various issues arise as a result of the police actions, being why did they ave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (fem: who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE) 2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes. Why was the response time so dramtically lengthier than prescribed and is this a matter of resources? (NWAS) 3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact it still did not generate a Red response, suggests that the algorithms used for coding are not accurate and not fit for purpose. In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied. (NWAS, SECRETARY OF STATE and NHS ENGLAND)

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2016-0194

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0