Elaine Tarbuck
7 Jul 2025 · Coroner Timothy Brennand · Manchester West
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of forced entry to residence
“Family members who lived far from the deceased became concerned for the welfare of the deceased and were of the view that she had suffered a medical episode, collapse or adverse event that explained her failure to respond to telephone calls and knocks on the door from friends.”
2. delayed forced entry
“The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased's residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.”
3. non-critical emergency classification
“calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event. This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend. 4”
4. unclear forced entry authority
“There was lack of understanding as to whether the forced entry would be lawful, a matter for the police, or a matter for Fire and Rescue Services in circumstances that the next-of-kin, if asked, would have agreed readily to there being forced entry at the outset and well before their arrival.”
5. sub-optimal information gathering
“There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler.”
6. wrong responder deployment
“The emergency response had come about because of a new 'Right Care, Right Person' policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased's residence.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call.”
This report
“The full background of the deceased, her history of falls, her recent bereavement and high risk to have suffered an adverse medical episode, or deliberate or unintended physical harm raised the expectation on the part of the family, that having called the emergency services, entry would be forced to the deceased's residence as they were of the view that there was a real and immediate risk of death or serious harm having occurred.”
Closely relatedConfidence 0.85 · high
This report
“The emergency response had come about because of a new 'Right Care, Right Person' policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased's residence.”
Later report
“An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted in a delayed deployment.”
Responses
2025-0342-Response-from-College-of-Policing.pdf ↗· College of Policing
Stated action
“The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear.”
2025-0342-Response-from-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
2025-0342-Response-from-North-West-Ambulance-Service-NHS-Trust.pdf ↗· College of Policing
Stated action
“NWAS, in partnership with Greater Manchester Police (GMP), has identified a recurring thematic issue involving calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare as outlined in the Right Care, Right Person stakeholder meetings. These concerns have been formally escalated to Senior Leaders within GMP and to the Deputy Mayor for further consideration and action.”