Investigation into police response after several calls end in man’s death – Greater Manchester Police, July 2023

Between August 2022 and July 2023, a man contacted Greater Manchester Police (GMP) six times to report that his neighbour had made threats to his and his son’s life. The man said that he lived in shared accommodation and believed his neighbour was experiencing mental ill health. The man said the neighbour had threatened him with a knife, thrown things at his window, kicked him, and he was scared for his and his son’s safety while living at the house.

Crime reports were opened for each call. The man said he did not want any action taken against his neighbour and just wanted the police to speak to him due to the threats made against his son. The reports were closed as it appeared that the man did not want to support a prosecution.

In July 2023, the man reported that his neighbour had threatened to kill his son again, and he was worried he would carry out the threat. He asked the police to go to his home.

The call handler told the man they would log the call and arrange for an officer to visit, but the police were not being sent at that time because there was no immediate danger. The call handler advised the man that if the situation escalated, he should barricade himself and his son in his room and call 999 immediately. Officers did not visit the man’s home, and the report was recorded and placed in the sergeant’s queue.

Later that day, another resident in the shared accommodation called the police to report that two of the residents were fighting. The police and an ambulance arrived and found the man, who had previously reported the threats from his neighbour, dead. The neighbour was arrested on suspicion of murder and was sentenced to a hospital order in January 2025.

We received a death or serious injury referral from the force and decided to independently investigate the contact between GMP and the man between August 2022 and July 2023.

We examined GMP’s handling of the man’s calls, their consideration of the risks posed, and whether this information was considered during the call he made on the day he died. We examined the police’s actions, decisions and risk assessments and whether their response to the man’s calls was appropriate. We also considered whether GMP’s handling of the man’s reports were influenced by race, age and/or gender, and whether they acted in line with local and national policies and procedures.

Our investigators reviewed the telephone calls made to GMP, together with the police incident logs and crime reports. Witness statements were taken from police staff, and legislation, national guidance and force policies were considered alongside the actions of the officers involved.

We concluded there was no indication that a person serving with the police committed a criminal offence or behaved in a manner to justify disciplinary proceedings.

However, we did find areas where the performance of call handlers and officers fell short. Risk assessments appear to have been inappropriate, given the man’s living situation, the likelihood of the matter escalating, and the history of violent and threatening behaviour. We found the police did not link information, which affected their ability to search for previous incidents that the man had reported, and they should have gathered more information by asking more questions in order to assess whether an urgent response was required.

We recommended that the performance of a number of call handlers and police officers should be addressed by their line managers, including the need to ask more questions during calls to elicit more information, and using that information to complete appropriate THRIVE assessments and grade calls effectively.

We found no evidence that police officers or staff were influenced by the man’s race, age or gender.

We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.

We found that residents of shared housing fall into a ‘grey area’ in terms of how they should be dealt with by police, and do not fit within the force’s current domestic abuse policy.

Our investigation also revealed that the details of both the man and the neighbour were incorrectly recorded several times. This led to incidents failing to be linked and information to be missed. We also raised performance issues around completing accurate THRIVE summaries and appropriately grading calls.

We are in the process of taking forward learning in these areas.

The force told us that the Digital Policing Programme is currently working towards the introduction of a new record management system. This new system should improve searching capabilities and significantly reduce the creation of duplicate records.

From August 2023, the Service Development Unit facilitated THRIVE training inputs for staff members, who are now trained to add full risk assessments to incident logs rather than summaries. This change assists with grading decisions and information that should be obtained at first point of contact.

Staff now have access to a database that contains up-to-date guidance and minimum standard questions that GMP have identified as essential to certain incident types. Call handlers are required to ask all minimum standard questions for the incident type they are dealing with to make sure they obtain relevant information immediately.