Hannah Warren

13 Feb 2023 · Coroner Edward Ramsay · Swansea Neath Port Talbot

The coroner's concerns

1. vehicle not located
“The evidence was clear that the most effective means of locating a missing person in [the deceased]'s position was to locate the vehicle in which it was assumed she was travelling”
2. risk assessment mismatch
“There was an apparent mismatch between the COMPACT risk assessment for [the deceased] graded as”
3. lack of guidance
“The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.”
4. inappropriate stop priority
“The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.”
5. absence of protocols
“I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.”
6. national guidance gap
“This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.”

Stated action

“The MPS Learning and Development directorate are in the process of adapting this national guidance into a MPS training package”