Student, 22, could have been saved from an overdose if police had left a voicemail for her parents during desperate search for her address
Amy Levy, 22, deliberately took an overdose of prescription pills at her student digs in Bristol while on the phone to a friend, who alerted the police as her condition deteriorated.
Two forces - Surrey Police and Avon and Somerset Police - launched a frantic search to find the University of the West of England (UWE) student and attempted to contact her parents in Surrey because they did not know her address.
But when officers tried to ring her parent's home phone and her mother's mobile, their number showed 'no caller ID' and the calls went unanswered.
No voicemail message was left despite the urgency of the situation.
Ms Levy was eventually located more than 90 minutes after the first police call, but died in hospital on June 22 2023 from an overdose of several medications, which caused hypoxic brain injury.
An inquest jury identified a 'catalogue of missed opportunities' to save Ms Levy, concluding she could have survived if police found her sooner, following a five-day inquest earlier this month.
Robert Sowersby, an Assistant Coroner for Avon, has now issued a report expressing concern about the lack of guidance issued to officers and staff regarding voicemail messages.
He said it was 'hard to understand' why the officers searching for Ms Levy did not leave a voicemail for her parents.
'Both police forces knew that Amy had taken an overdose at an unknown address and that her condition was deteriorating,' his report said.
'Both forces had graded Amy's case as requiring an 'immediate' response, the most urgent category.
'Despite that factual background, none of the officers or call handlers who phoned Amy's parents left a voicemail message.'
He said that, because the missed calls were from an unknown number, Ms Levy's parents did not know that there was an emergency, or that the police wanted to speak with them, and had no way of calling them back.
He wrote: 'It is probable that Amy's location could have been obtained earlier than it was if the police had left a suitably worded voicemail for one or more of her parents.'
The conclusion of the jury who heard the inquest was that: 'Amy took a deliberate overdose of prescription drugs on 18th June 2023. It is not possible to know her true intent.'
In recording how Ms Levy died, the jury identified 'a catalogue of missed opportunities to obtain Amy's correct address' by various bodies including Surrey Police and Avon and Somerset Constabulary.
The jury also concluded that if not for those missed opportunities Ms Levy would probably have survived.
Mr Sowersby continued in the notice: 'This was an 'immediate' priority search to obtain the address of a young woman whose life was believed to be at risk.
'It is hard to understand the decision made by more than one police caller not to leave any voicemail/message.'
Police inspectors from both forces gave evidence at the inquest that there was nothing to have stopped messages being left.
One said there was guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, but there is no general guidance about when to leave a voicemail message in other cases.
Mr Sowersby said: 'With limited or no guidance, training or policy on when police and/or police support staff liaising with the public should leave a voicemail, particularly in circumstances where they are trying to obtain important information in a time-pressured situation, I am concerned that there is a risk that future deaths will occur unless action is taken.'
Responding to the coroner's report, Superintendent Chris Colley of Surrey Police said: 'Our thoughts and condolences remain with Amy's friends and family following what must have been a very hard couple of years for her loved ones.'
He added: 'We have now made changes to our procedure around the use of voicemails and telephone contact attempts, to ensure we are doing all we can to be there for people when they need us most.'
A spokesman for Avon and Somerset Police said: 'Our thoughts are with the family of Amy Levy, who died in extremely tragic circumstances two years ago.
'A private apology has been made to her family, which we wish to repeat publicly, and we are reviewing our organisational policies in line with the findings relating to this case.'
A College of Policing spokesman said: 'National guidance for officers is regularly reviewed to ensure it provides accurate and practical advice for police forces.
'Our reviews take into account information and advice from a range of sources, including coroner's reports, and we will carefully consider the recommendations made from this tragic case.'
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