Lucasz Lewandowski
15 Oct 2014 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed police response
“The timeliness of GMP's response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols.”
2. delayed emergency mental health response
“Lack of communication between GMP and MEDACS regarding the existence of their escalation protocol resulting in the delayed attendance of an FME.”
3. breakdown in continuity of care
“The psychiatric practice's failure and reluctance to correspond with a patient's GPs and/or other healthcare professionals following consultation, jeopardising continuity of care.”
4. inappropriate clinical decisions
“Clinical decision-making by a non-medically qualified Practice Manager.”
5. misplaced responsibility for patient safety
“The view of the physician - that responsibility for maintaining a patient's safety and wellbeing within the community rests entirely with the family and/or patient rather than the clinician.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The timeliness of GMP's response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols.”
Later report
“In relation to the grading of the lncid.ent relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the Incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident”
Responses
2014-0445-Response-by-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
Stated action · final stages
“The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention”