Unblurring the Lines

Another recent Preventing Future Deaths notice from a Coroner has pricked my attention, concerning the sad death of Hannah Breadshaw from Greater Manchester.  Inevitably, PFDs are brief and not all details are included, but to my reading, this may be about the ever-blurred distinction between a threat to life incident and a somewhat more routine “welfare check”.

The relevant timeline regarding a call to Greater Manchester Police (GMP) about Hannah’s welfare is given as –

  • A friend of Hannah’s rings GMP at 12:30pm to raise “welfare concerns” and it was allocated a 1hr response time;
  • An ambulance was requested at 12:45pm and they arrive on scene first, at 2:10pm;
  • They request police for force entry at 2:26pm and chase GMP several times over two hours until police arrive at 4:47pm;
  • Entry forced, patient found deceased.

The IOPC were informed of the incident and they flagged three particular concerns prior to the inquest.  1)  a failure to escalate the incident, 2) a failure to make method of entry equipment more readily available; and 3) issues about document management (unspecified).  For me, the PFD raises a number of questions I can’t answer because the detail relevant to determining them is not included in the PFD and this would appear critical to understanding the implications of this sad case:

  • Was it known by GMP at the point of reporting or any stage prior to arrival as being a “threat to life” incident? – allocation of a 1hr response time suggests not, but perhaps it was not graded correctly.
  • The PFD states Hannah had researched methods of taking her own life the day before she died, but it’s not clear whether that was known to her friend and / or passed on to the police.
  • The PFD also states Hannah’s friend was asked by the deceased to make sure her cat was looked after, implying suicidal ideas but whether this was passed to GMP is not clear.
  • The PFD talks not of suicide or threat to life, but “welfare concerns” being made known to the police.
  • If the ambulance were requesting forced entry at 2:26pm, that implies they are requesting entry to save life and limb (s17(1)(e) of PACE) – did they flag “threat to life issues” as the basis for the request if so, what re-assessment was done by GMP at that point or during the two and half hours which followed, until they arrived?
  • If that wasn’t the basis of the request, what did GMP make of the request given that entry only can be forced to save life and limb? … you may remember the stated case in 2010 of Syed v DPP, in which a civil claim was brought against the police for forcing entry.
  • Long story made short: Mr Syed won – you can’t force entry to a premises for a welfare check unless it is also a threat to life.


The first question that should be asked in a report which amounts to a “concern for welfare” is whether it is known or suspected to be any kind of threat to life.  This is for important legal reasons:  firstly, the police service have clear and unambiguous responsibilities to protect life and, for example, can force entry to any premises in order to do so.  It is less clear around what are sometimes called “concerns for welfare” or “welfare checks”.  Clearly, anything amounting to a threat to life is also a concern about someone’s welfare, but the reverse is not always true.  We can be concerned that someone is not OK whilst not necessarily believing their life is at risk – understanding this stuff is key, not least because the police cannot force entry to someone’s home for a “welfare check”.  The Syed case above involved a situation where the police purported to rely on the “life and limb power” under s17(1)(e) of PACE for a welfare check and the court ruled this was inadequate.

So understanding the information being offered is crucial and if necessary, non-leading questions should be asked of callers to make sure this is clarified as well as possible (and it won’t always be possible).  That’s why my second batch of bullet points, above is key to my understanding of this particular case.  One version of events may be that Hannah’s friend knew she’d be researching suicide, told that to the police at 12:30pm and it makes the response look inadequate on all viewings.  Another version might be that Hannah’s friend did not know the research she’d done prior to ringing about “welfare concerns” or, if she did, wasn’t clear about that point (no criticism – some callers aren’t quite sure what information is needed and one can imagine making a call like that about a friend, whilst worried, would be stressful).  So perhaps GMP did think this was a concenr for welfare not amounting to an immediate threat to life.  Then we need to know if that was re-framed after arrival of the paramedics:  them seeking forced entry should be a trigger for reconsideration – it is either thought by the ambulance service to be a threat to life or it’s not.  Did they flag it as such and if not, what did GMP make of the request for forced entry (bearing in mind it can only be forced if it is a “life or limb” incident.

This is why unblurring the lines to ensure clarity about what is a threat to life incident (with an Article 2 ECHR duty), and what is “just” a concern for welfare (no legal obligation for the police, per se and no power of entry) is so important and the distinction should be drawn in all policy relating to this and reinforced to call handlers who are key to ensuring the threat and risk involved is properly understood.

UPDATE (100522) — since writing the post, I have learned of another article giving a more detail.  It still leaves many of the questions above, bouncing in my head so I’ll leave the original post untouched, but wanted to provide the additional report, in fairness to all involved / affected.  A very sad case.

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All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown OBE, 2022

I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

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