Greater Manchester Police took more than eight hours to respond to an emergency call expressing concern for a troubled woman with a history of mental health difficulties, an inquest heard.
After a worried pal called GMP about Angeline Phillips, the force ignored its own policy to dispatch a cop to the 'grade two' call within an hour and instead told an ambulance crew to attend, the hearing was told.
An inquest heard paramedics left the scene as there was no answer to the door and that GMP finally dispatched an officer eight hours after the initial call. An officer finally broke into the home and found her dead after a further hour.
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Ms Phillips, 35, who was diagnosed with personality disorder, was found dead at her home on Wilbraham Road in Walkden on January 30, 2021. She died of an overdose.
Known as Ange, she had been admitted to hospital with reported overdoses 28 times in the three years before her death, and had been sectioned and discharged five times as part of a 'cycle' that could not be broken, an inquest in Bolton heard on Wednesday.
Forensic pathologist Dr Jane Robinson, who conducted a post mortem examination, concluded the death was caused by toxicity to two drugs. The court heard the former is a strong pain killer which had not been prescribed to Angeline by her GP while the latter is not prescribed in the UK but is available to buy on the psychoactive drugs market.
Both drugs were found in quantities 'consistent with recreational use or excess', according to a toxicological analysis. The effect of consuming both at the same time 'may be considerable', the pathologist said.
Friend called GMP but no response for hours
The inquest heard Angeline's friend Molly Winder called GMP at 6.09pm on January 29, 2021, concerned she had not heard from her for 24 hours and that she had attempted suicide previously.
The call handler categorised the call as a 'grade two' emergency, one below the most serious 'grade one' call. GMP's own protocol requires an officer to attend a grade two call within an hour, the inquest was told.
But the force didn't dispatch an officer at that stage and decided to refer the incident to North West Ambulance Service (NWAS) at 8.32pm, almost two-and-a-half hours after the initial call.
The inquest heard that at 11.06pm NWAS indicated an ambulance had attended the property but there had been no answer and the crew had been called to another incident by someone who approached them on the street. It was only some seven hours after the initial call that an officer from GMP was told to go to the house, at 1.07am.
The officer first made checks with hospitals and social media and eventually attended the property at 2.29am but there was no answer, the inquest was told.
More officers trained in forcing entry were sent to the scene and they broke into the home at 3.48am, the inquest was told. Ms Phillips was found dead on her bed.
Joseph Heaford, who investigated the police response for the Independent Office for Police Conduct (IOPC), agreed with the coroner he had 'no issue' with GMP deciding the call was a 'grade two' emergency as there appeared to be no immediate threat to life which would require a grade one response.
Mr Heaford, now a constable at GMP, agreed the force's response that night was at odds with its own policy for a grade two emergency. He agreed the force should have dispatched an officer within an hour and should not have referred the case to NWAS.
The inquest heard that GMP had 11 logs on its system concerning Ms Phillips in the twelve days before her body was found, and that all but one of them were reports of concern for her welfare.
But Mr Heaford said he found no evidence that GMP had contributed to the death as it was not possible to say when she died.
The police investigation found Ms Phillips had made her last financial transaction, an Uber Eats purchase, at at 7.44pm on January 28, 2021. She had also sent a 'confused' text that night, the inquest was told. Police found no evidence she was alive after the evening of January 28, the court heard.
Prof Dr Alan Walsh, the coroner, criticised GMP's response. He said: "I'm concerned about action being taken that this does not happen again. That's my major concern and I'm sure that's the family's major concern."
Angeline had mental health struggles and overdoses, inquest hears
Dr Nisham Bhandari , a consultant psychiatrist who treated Ms Phillips, told the inquest she had been admitted to hospital following reported overdoses, sectioned under the Mental Health Act and the discharged on five occasions between July 2019 and her death. On the last occasion, she was discharged to stay at a Premier Inn rather than at home.
Asked about the cycle which appeared to be repeating itself in Ms Phillips' care, Dr Bhandari said 'crisis' admissions into hospital often helped patients.
Senior mental health nurse Siobhan Hare assessed Ms Phillips at Salford Royal Hospital on January 27, 2021, after another reported overdose. Ms Hare said the patient left the hospital of her own accord without her assessment being completed, although she appeared 'very alert'.
Consultant psychiatrist Catherine Symonds told the inquest she saw Ms Phillips at Royal Bolton Hospital following another reported overdose on January 28.
The court heard blood tests revealed the drugs she said she had consumed were not in the quantities she had suggested and she did not appear to be drowsy. Dr Symonds said the patient informed her she had suffered physical and sexual abuse 'in the past' and that she had been raped on January 20.
But the patient did not want to discuss the alleged abuse and declined the offer of 'prescribable alternatives' to the drugs she had consumed.
Ms Phillips told her she did not feel safe at the Premier Inn and would feel safer at home, the inquest was told. The patient had told her she wanted 'to be dead' and appeared to be 'desperate and emotionally distraught', said Dr Symonds.
But the doctor said she was aware Ms Phillips had presented to hospitals in similar circumstances 29 times since 2018 and that although she was at risk of an overdose, she did not believe any overdose would result on 'significant medical consequences'. Ms Phillips declined a voluntary admission to hospital and she was discharged.
Coroner Prof Walsh said he was 'a bit surprised' that nobody from GMP had attended the inquest. He said his office had been in touch with the force which had requested 28 days to respond to any criticisms.
The coroner said he had had 'sufficient concerns' to consider penning a report about GMP's involvement but he wasn't prepared to give GMP that long. He adjourned the hearing until December 5.
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