Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0442, written 13 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2014 |
|---|---|
| Reference | 2014-0442 |
| Deceased | Arsema Dawit |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
HM Coroner, London Inner South Re Arsema Dawitt case ref 01589-2008, died 02.06.08 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS \ This report is being sent to The Commissioner, Metropolitan Police Service CORONER | am Andrew Harris, senior coroner for the coroner area of London Inner South CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ma INVESTIGATION and INQUEST | opened an Article 2 inquest following a High Court Order in November 2012 into the death of Arsema Dawit, aged 15, on 02.06.08. She was stabbed by a former friend who had been stalking her. The conclusion of the inquest delivered by the jury on Friday 26th October 2014 was unlawful killing, (dying from multiple injuries). CIRCUMSTANCES OF THE DEATH The jury described the circumstances of the death, an extract of which follows: “Her death follows the report the family made to the police on 30.04.08 in which they reported several incidents relating to the deceased. This report was recorded on the CRIS system, the limitations of the CRIS report enabled several assumptions to be made. The principal offence was recorded as ABH and the investigation followed this line of inquiry. Had the principal offence been recorded and verified as a threat to kill, a risk assessment would have been carried out, which would have recognised and prioritised the threat to kill as urgent. The subsequent police investigation was inadequate for a threat to kill. The police investigation was insufficient and not carried out in a timely manner. There were insufficient measures taken in trying to communicate with the family as interpretation was required and the family home was not visited... There is no evidence of the family contacting the police during the month of May after the initial report. There was minimal supervision of this case and the case was hampered by the denials of the deceased that a report had ever been made.” CORONER’S CONCERNS It is clear that there was a significant time between the report to the police station and her death, and that the investigation was hampered by the deceased’s subsequent denial at her school, of attending the police station. It is also clear that the period of investigation coincided with changes in police systems and staffing pressures. Nevertheless, during the course of the inquest the evidence revealed matters giving rise to concern about police operations. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The senior reception officer prematurely classified the offence, failed to reclassify it when the full details were known at the end of her interviews and entered a misleading entry on the CRIS that the Inspector whom she had briefly asked a question, had been informed of the incident, which he had not, but others assumed he had been. He was clear that had he known the full account of the incident, he would have required further steps to be taken at the outset. Is the SRO appropriate to complete the CRIS in such a case and is the system of recording and reviewing the entered principal offence now understood by reception officers? (2) The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence, when the case was reviewed by senior supervising officers, nor was a linked crime report made. The entry of the second Inspector was insufficient to properly inform others of his decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who then did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations. (3) The action plans that were adopted appeared to have been supervised sub-optimally by Detective Sergeants. It is not clear whether these were individual weaknesses or reflect a wider weakness in the role of supervisors. (4) According to the MPS Standard Operating Procedures at the time, the offence could not have been reported as domestic violence as those involved were not adult and was outside the remit of the child abuse investigation team. There appeared to be a gap, which might mean inappropriate or insufficient investigation could be carried out. (5) There appeared to be some reluctance to use the interpreting service, so that the mother was never interviewed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe the MPS have the power to take such action and/or report on such action as has been taken with respect to these five concerns. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 7" of December 2014, |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have s port to the Chief Coroner and to th Persons lof Ziadies (Solicitors for the famil Reynoldsdawson Solicitors (Solicitors fo: if MET Police, f Stoneking Solicitors for Harris Academy (School) and to Mr Lambeth Strategic Safeguarding, Assistant Director Multi-Agency Family Support and Child Protection. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. If you wish to have further information or assistance please contact the officer, Ms Jo Bull (020 7 525 0965 and email] [DATE] [SIGNED BY COROWE 13" Oebib foie alla
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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“Gebibahcaeee TOTAL POLICING
Specialist Operations
Dr, Andrew Harris,
Senior Coroner, Room 1805, Tower Block,
Inner South District of Greater London New Scotland Yard
The Coroners Court 10 Broadway
1 Tennis Street London
Southwark SW1H OBG
London SE1 1YD
Tel: 020 7525 4200 (main office) Telephone: nn
Fax: 020 7525 6356
Email:
Our ref: |
Fs Clerk to the Coroner
Te)
20th November 2014
Coroners Officer:
Te)
| write in response to your Coroners Report to Prevent Future Deaths, dated 13th October 2014, following
the Article 2 inquest opened by you in November 2012 into the death of Arsema Dawit, aged 15, on the 2nd
of June 2008. The conclusion of the inquest, delivered by the jury on Friday 26th of September 2014 was
unlawful killing of Miss Dawit. Although the jury did not find the role of police in the incident had contributed
more than minimally to the circumstances of the death, in their narrative accompanying their verdict they did
draw critical attention to a number of aspects of the police handling of the situation. These included
limitations in the taking of an initial report made by Miss Dawit of abusive behaviour towards her by her later
killer, the recording of the principal offence as Actual Bodily Harm rather than as a Threat to Kill; a
subsequent investigation ‘inadequate’ to a threat to kill reported by Miss Dawit in her initial approach to
police; a lack of timely investigation; poor communication with the family; and minimal supervision of the
case. The jury additionaily noted the deceased’s later unwillingness to assist which hampered the police
investigation of the initial incident.
You identified five matters of concern, which | paraphrase and respond to here. My comments have been
informed by discussion with subject-area specialists.
1: Initial classification by the SRO
You pointed out that initial classification of the offence by the civilian Station Reception Officer (a role now
occupied by the broadened function of ‘PAO’ -Public Access Officer) was incorrect; and that an entry written
by this staff member on the Crime Report Information System (‘CRIS') implied that a brief question asked of
an Inspector during the taking of the initial report amounted to informing him of the incident, and therefore
that a senior police officer had reviewed the facts. This was not the case. You asked: “Is the SRO
appropriate to complete the CRIS in such a case, and is the system of recording and reviewing the entered
principal offence now understood by reception officers?"
Response:
A decision was taken by Management Board in 2007 that the Station Reception Officer (SRO) role would
cease to exist with effect from 31 July 2008. Initially, those staff recruited to the revised position after this
date were called ‘Station Police Community Support Officers’ (‘SPCSOs'), who were part of the Police
Community Support Officer family. Patrolling had not formerly been part of the remit of the SRO, and so
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these officers received the standard training in respect of the patrol and other ordinary duties of the PCSO,
together with training on the subjects of criminal investigation, victim care, missing persons investigation, as
well as a number of other, front counter specific tasks. Subsequently, under Territorial Policing
Development's Public Access Project, the MPS again revised the definition, replacing it on the 1st November
2012 with the still-current role of Public Access Officer (PAO). Though there is now no patrol element to the
role, the new post i notably broader in remit than both the SRO and the SPCSO which preceded it. PAOs
are now trained for and work exclusively as specialists within the front counter environment. Their
responsibilities and training have been extended to include statement taking, the initial recording of
complaints against police, and the administering of an appointments system.
The current PAO training course was designed centrally in conjunction with MPS training command, known
as ‘Met Training’ and is delivered by dedicated trainers from Met Training. It takes place over 13 days and is
a mandatory requirement before a new staff member can take up a post within the MPS. Attendance on and
successful completion of the course is monitored by line managers on the trainee’s home Borough
Operational Command Unit (‘(BOCU’), The curriculum of the course covers all aspects of the role of staffing a
front office or other public access point. Topics covered most relevant to the Dawit case include:
¢ Customer service - Including listening and questioning skills, and awareness of how fo access the
24/7 ‘Language Line’ instantaneous telephone translation service now available at every point of
public contact. (for more on translation services, see below).
* Primary investigation - Including every stage of the initial investigation that would be required in °
every crime - captured in the concept of ‘Research, record, retain and refer’. The ‘refer' lessons in
particular are dedicated to ensuring that the correct parson is appraised in order to take the
investigation forward and manage any associated risk - clearly addressing the initial oversight
highlighted by the jury in the present case.
Critical Incidents - including how to recognise one, what to do when they occur, and who to inform.
Domestic Abuse
Total Victim Care
It is worthy of note that these lessons are very similar to those given to a PC recruit. Every member of our
frontline engagement with the public, whether officers or staff, thus begin the first day of their appointment to
a station with a similar set of decision making tools, and are encouraged to think of themselves as ‘initial
investigators’ from the moment they begin taking any report.
Where a number of possible offences could describe a sequence of events prompting a report to police, the
rule is and always has been that the most serious should be the one under which the report is initially
classified. It is acknowledged that an early oversight in the Dawit case was in failing to identify a ‘threat to
kill’, treated as background to a lesser, but more evident offence of Actual Bodily Harm. Whilst it of course
will always be the case that individuals may make questionable decisions, (which our supervisory processes
are designed to identify and rectify, see below,) there is no inherent reason why, given the preparation we
give our staff, and the business processes that we have instituted, that a report taken by a PAO should not
now be as detailed and investigatively useful as one taken by any officer. In short, in answer to your
question: "Is the SRO (PAO) appropriate to complete the CRIS in such a case and ig the system of recording
and reviewing the entered principal offence now understood by reception officers?”, notwithstanding the
particular facts in the Dawit case, we would answer ‘Yes.’
Underlying the whole of the input received by PAOs is the National Decision Model, an Association of Chief
Police Officers-endorsed tool now employed by ail forces to provide their officers and staff with a baseline for
engaging with any issue requiring an operational decision of some sort. The National Decision Model (‘NDM’)
is designed to be suitable for all decisions. it can be applied after spontaneous incidents or before planned
operations, by an individual or teams of people, and to both operational and non-operational situations.
Decision makers can use it to structure a rationale of what they did during an incident and why. Managers
and others can use it to review decisions and actions taken. The inherent flexibility of the NDM means that it
can easily be adapted for any task within policing. in every case, the decision making model stays the same,
but users decide for themselves what questions and considerations they should apply at each stage. Any
person addressing a decision (e.g. “What do | do with this allegation?”) is therefore expected to begin by
asking themselves:
« 1s what I'm considering here consistent with our Statement of Mission and Values? (i.e. decisions
must reflect the police duty “...to act with integrity, be willing to take risks and protect the human
rights of alf.”)
« What would the Police Service expect of me in this situation?
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e What would any victim(s), the affected community and the wider public expect of me in this
situation?
Having considered this, the NDM then directs any decision maker to consider five complementary areas to
inform their decision: information gathering, assessment of risk, consideration of powers and policies,
identification of options, then finally, action and review. | do not propose to replicate the guidance offered
under afl these stages in detail here, but the first two of these perhaps illustrate how the questioning stance
the NDM encourages users to adopt should have potentially informed the decision making process of the
Station Reception Officer in the Dawit case, had it been available af the time:
“Stage 1: INFORMATION Gather Information and Intelligence
During this stage the decision maker defines the situation (ie, defines what is happening or has happened)
and clarifies matters relating to any initial information and intelligence.
* What is happening?
* What do | know so far?
« What further information (or intelligence) do | want/need?
Stage 2: ASSESSMENT - Assess Threat and Risk and Develop a Working Strategy
This stage involves assessing the situation, including any specific threat, the risk of harm and the potential
for benefits.
* Do | need to take action immediately?
* Do I need to seek more information?
« What could go wrong? (and what couid go well?)
« How probable is the risk of harm?
* How serious would it be?
+ Is that level of risk acceptable?
+ Is this a situation for the police alone to deal with?
« Am | the appropriate person to deal with this? (my emphasis.)
As can be seen, a person following the thought process encouraged by the model would automatically be
called upon to risk assess any threat made, to identify ‘gaps’ (such as the communication Issues highlighted
by the jury), and to seek appropriate guidance.
In support of such better decision making, a further innovation since 2008 has been the refashioning of our
sometimes unwieldy policies and procedures into a series of user-friendly ‘toolkits’, available 24 hours a day,
seven days a week, from any MPS computer workstation. These are designed to be clear, concise guides,
‘Frequently Asked Questions’ and checklists which can support any frontline officer or staff member before,
during, or after dealing with any situation which they may be unfamiliar with. For example, links to an easy to
follow flow chart of necessary actions setting out how a ‘Threat To Life’ should be recorded, reported, and
progressed is now included in a bespoke online reference guide, the Reception Services Manual, for use by
Public Access staff, This manual contains, infer alia, specific guidance on how to deal with:
Threats to life*
Critical Incidents
Domestic Abuse
Vulnerable Adults
All of which would have been of potential relevance in the present case.
*Please note ~ ‘threats to life’, whilst it may wel! incorporate instances of the criminal offence of Threats To
Kill, contrary to s.16 of the Offences Against The Person Act 1861 { “...A person who without lawful excuse
makes to another a threat, intending that that other would fear it would be carried out, to kill that other or a
third person shail be guilty of an offence”), more specifically describes the broader issue of responding to
credible intelligence being received from any source that a life is at risk, in line with National Guidelines on
the topic.
Such intelligence may at the point of receipt not always amount to a clearly identified offender, victim, or
offence. (Indeed, in the Dawit case, although the name of the boyiien ara was given, it
was given incorrectly and no other identifying detail - i.e. DOB or address - was provided with it. )
Consequently, an early stage of the risk assessment of any such threat, now clearly set out in the ‘Toolkit’
20/11/2014 Page 3 of 10
mn,
flowchart referred to above, is to decide /f an allegation of a substantive offence of a threat to kill has already
been made out. If so, then the investigation of the alleged crime, once recognised as such, will automatically
attract an enhanced level of threat assessment from a suitably qualified investigating officer; and the
interdiction of the threat will proceed as for any other allegation of serious crime (escalated to CID to deal,
etcetera). Equally, if more intelligence work needs to be done to substantiate a possible risk, or steps taken
to warn or protect possible targets and so on, then there is nowa clear management process in place to
direct these efforts. Introduced MPS wide in 2012, we call this ‘Grip and Pace’.
The overarching rationale for Grip and Pace, developed as part of the Met Change programme, is to ensure
that there is an effective 24/7 police response connecting and driving business and service commitments,
replicated on every borough. In each case this takes the form of a single co-ordinating point — the ‘Grip and
Pace Centre’ - which has access to and oversight of all the critical personnel and resources (intelligence
systems; equipment; vehicles) required. This local co-ordinated resource tasking and deployment system is
focused on the concepts of possible ‘harm’ presented by individuals and situations, ‘opportunities’ to
Intervene in these, and ‘threats' to our ability to intervene. These factors are dynamically assessed by
experienced ‘Harm, Opportunity, Threat’ (‘HOT’) supervisors. Their assessments then drive key tasking
decisions. This process can be summed up as having a "Grip" on Borough resources and responding to the
developing "Pace" of the day, with the intention of identifying short term and longer term crime patterns and
trends, and ensuring we have the right people in the right places at the right times to deal with incidents as
they arise. The model depends for its' effectiveness on three ‘Pacesetter’ review meetings conducted at
regular intervals throughout the 24 hour day, involving a number of co-located key personnel deployed to
specific roles:
The on-duty Senior Leadership Team lead takes responsibility for the deployment plan and provides 'Real
Time' leadership on daily activity by tasking available assets to support intelligence-led policing. The HOT
supervisor provides continuous assessment of potential Harm to individuals or situations identified in
information as it comes in, Opportunities (to intervene) and Threats (intelligence on the sources of the risk),
responding immediately to changing circumstances. This is achieved through constant monitoring of
Computer Aided Despatch system which initiates the response to calls, and documents their resolution,
supported by our crime recording system, CRIS, and our intelligence systems lIP (Integrated Intelligence
Platform) and MERLIN (Missing Enquiries and Relevant Links Indices). By locating oversight of these
functions with a single, named HOT supervisor, this achieves a dynamic, accountable ‘ownership’ of risk in
any evolving situation. Meanwhile, Fugitive Management identifies, traces and monitors wanted and missing
offenders for incidents, and relays progress to the HOT supervisor and SLT fast-time resource deployment.
Any report of a ‘threat to kill’ received now and recognised as such would therefore immediately trigger a
comprehensive intelligence and threat assessment, and response.
Collectively, the intention is to ensure that this Grip and Pace team, all operating from a single location on
each Borough know where crimes are happening, who the suspects might be and what resources we can
deploy to prevent or apprehend them, from first report to resolution of the incident. How this might tink into a
report taken at the front counter is set out below.
2: Initial Classification issue
You wrote:
"The court was told that most serious crime reported should be the principal offence, but the threat to kill was
not entered as the principle offence, when the case was reviewed by senior supervising officers, nor was a
linked crime report made. The entry of the second inspector was insufficient to properly inform others of his
decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who then
did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear
whether this was a series of misunderstandings or a systemic or cultural failure to properly document and
ensure flexibility in investigations."
Response:
As above, we have acknowledged the initlal error made in failing to classify the CRIS report under the most
serious offence alleged, the threats to kill, and accept that such initial classification errors by the original
submitting officer or staff member, on occasion compounded by subsequent oversights by supervisory
officers may, despite the training and support we have already discussed, still occur. It is important to realise
however that the initial recording officer does not confirm the classification (and thereby, it's onward route
through risk assessment, investigation, etcetera). Nor, since 2012, do local investigators or their managers.
Confirmation of that initial classification was then and remains today a supervisory function. However, the
20/11/2014 Page 4 of 10
significant improvement in our business processes since 2008 has been the introduction in 2012 of a
centralised, independent quality assurance layer which assumes responsibility for the confirmation of initial
classification for aif reported crimes MPS wide. This centralised independence provides an opportunity to
correct local errors of the type which occurred in the initial recording of Miss Dawit's allegation. The
supervision is provided by the Crime Assessment Unit (CAU), comprising three teams of experienced
detective and uniformed officers and staff, each headed up by an inspector. The CAU run a series of
automated searches to ensure that any reports lacking the necessary classification confirmation undertaken
by them are reviewed and progressed appropriately. Their expertise and familiarity with Home Office
Counting Rules and National Crime Recording Standards ensures a high degree of ethical, corporate,
consistency in the confirmation of any initial classification. A CAU team will review, confirm, and if necessary
amend classifications. This is undertaken against a national target of correct classifications being confirmed
as soon as possible, and, exceptionally, within an outermost limit of 72 hours.
Inspector IEEE, of Team 1 CAU was asked what would happen in the event of the initial Dawit
CRIS appearing today. He is confident that the team’s review function would pick up the threats to kill
‘hidden’ in the details section of the original report. The crime would therefore have been reclassified
correctly at an early stage, opening the way to appropriate risk assessment, enhanced intelligence checks,
and early investigative action. The CAU team enabie this by redirecting the report back to the submitting
Borough's ‘Grip and Pace’ function, as discussed above, where it would fall to the ‘HOT Supervisor’ to
conduct a minimum full five year intelligence checks on victim and suspect, and to take any other necessary
local action to ensure that the crime was triaged to appropriate local resources to actively progress the
investigation.
3: Supervision of Action Plans
You wrote:
“The action plans that were adopted appeared to have been supervised sub-optimally by Detective
Sergeants. It is not clear whether these were individual weaknesses or reflect a wider weakness in the role of
supervisors.”
Again, we acknowledge that individual officers may make poor decisions. Mitigating this risk requires
recruiting, training, and developing the right people; providing them with the support systems to enable them
to operate effectively; and building corrective procedures into the way we undertake ordinary business. The
aims of any robust investigative process should therefore incorporate means to limit the scope of any poor
decisions to cause harm to the investigation, and to enable the prompt identification and rectification of any
shortcomings, through routine activities such as regular review periods, oversight by more senior line
managers, and so on.
Since 2008, considerable work has been undertaken nationally and within the MPS on these fronts,
beginning with a number of significant changes nationally and within the MPS in the training and support of
all newly promoted and serving uniformed and detective officers.
For example, all successful candidates in constable to sergeant promotion processes, whether uniformed or
detective, are now required to take a number of National Centre for Applied Learning Technologies
(‘NCALT) self-taught computer based training modules on topics such as the aforementioned National
Decision Model, before attendance at a mandatory ‘new sergeants’ course. Between 2010 and 2014, this
course ran for 5 days. Emphasised, amongst other topics, are the concepts of intrusive supervision, and of
being able to evidence effective supervision through documenting action plans, decision making, and
delegating processes in entries on official reports, decision logs, and so on. This course was enhanced and
extended to seven days in May 2014. The initial classroom element is also now complemented by a six-
month probationary period, during which, whilst all newly promoted sergeants are undertaking their new role,
they are expected to successfully complete a workbook of evidence showing how they address a range of
typical supervisory tasks. These requirements are common to all newly promoted sergeants.
Work is also in hand to further develop continuous professional development for all in-post officers and staff,
through the ‘Leading for London’ programme. To be piloted across seven pilot sites early in 2015,
(Westminster, Haringey, Southwark, Met Prosecutions, SCO19 Specialist Firearms, SCO17 Sexual
Offences, Exploitation and Child Abuse and SO14 Royalty Protection) with the eventual aim of a London-
wide roll-out, this is a practical skills-based ‘roadmap’ available to all. For the first time in one clearly
understandable iniranet ‘document’ it will set out the knowledge, skills or behaviours one will be required to
evidence at each stage of a career within the MPS, and the different development modules one will need to
20/41/2014 Page 5 of 10
support this progress over time. It highlights the leadership skills officers and staff at any rank or grade need
to meet current challenges and deliver the best possible policing for London. The core identified skills are;
Valuing and promoting diversity and inclusion
Being self-aware and understanding your impact on others
Empowering others
Encouraging challenge and seeking feedback
Delivering change through collaborative working and problem solving across the Met and other
partners;
e Adapting your approach to suit the situation and context
In addition to ail of the above, Detective candidates are additionally required to pass an internal selection
process for the role, be recommended by their current line management for it, then to evidence their practical
competencies in a rigorous, skills-based Detective Development Programme, followed finally by a
knowledge-based test, the National Investigators Examination.
Once in post, any detective of any rank in an active investigative role is thereafter required to provide
evidence in their annual performance review of their continuing professional development. Within the MPS
all supervising detective sergeants newly promoted under this process, or detective sergeants who qualified
under earlier legacy processes, are also further required to attend at least one further, practically-based
investigative skills course, the Initial Management of Serious Crime. A key learning objective on this course
is to:
e “Explain the importance of maintaining a record of decisions giving direction to an enquiry and
prioritising team activity.”
The centrality of clear investigation plans and logs of actions undertaken is therefore now fundamental to the
MPS understanding of the role of any detective supervisor.
The ‘Toolkits’ concept we have already touched on above is also relevant here. In support of any supervisors
drafting of a bespoke action plan for a crime, the MPS now has a set of aide memoire for use by all primary
and secondary investigators and supervisors of crime, directing their attention to relevant factors. Based
around a core toolkit, the ‘General investigation of Crime’, supporting checklists cover in greater detail some
of the issues to consider when investigating certain common offence types. Of potential relevance in the
Dawit case would have been the enhanced guidance available in the Domestic Abuse tooikit directing the
investigator to consider use of interpretation services, Risk Assessment, and where relevant, the
Vulnerability Assessment Framework, For example, the MPS defines vulnerability as something which:
*,..May result from an environmental or individual's circumstance or behaviour, indicating that there
may be a risk to that person or another. Those who come to notice of the police as vulnerable will
require an appropriate safeguarding response. Additional factors to vulnerability may include Mental
Health, Disability, Age or illness and should include an appropriate multi-agency intervention,
especially in cases of repeat victimisation.” [my emphasis]
Here, Miss Dawit’s youth, in relation to the (initially reported ‘30 year old’, in fact 21 year old) suspect was a
tisk factor; as was her status as a child of 14, which would engage another toolkit, on child safeguarding.
Both of these factors — her youth, and her potential vulnerability — require a ‘Merlin' database entry to be
created, and indeed this was done in her case. A Merlin entry provides the gateway to enhanced intelligence
checks on the family details, and to inter-agency problem-solving co-operation with Social Services, Health,
and Education.
A new development in this area since 2008 is the establishment of the ‘Multi Agency Safeguarding Hub’,
(‘MASH’), which co-locates safeguarding agencies and their data into a secure assessment, research and
decision making unit which receives ail notifications relating to safeguarding and child welfare from any
source in each Local Authority area. These are in the process of being extended to include vulnerabie adults,
adding additional value and providing a hub for activity around families. By a MASH providing a fire walled
Though see the issue with national definitions discussed at point #4 below
20/11/2014 Page 6 of 10
mm,
environment each partner agency is assured of the confidentiality of the process and that any resultant
dissemination of partner agency information in a safeguarding intervention (particularly important for police
and health) is proportionate. The model also allows for processes regarding missing people, domestic abuse,
child exploitation and others to be included.
These hubs review all Merlin reports, risk assess them, and where appropriate convene multi agency
problem solving meetings, to which relevant third parties, such as a local investigator dealing with a case
Involving a MASH subject, may be invited. The MASH also creates action plans for the partners involved,
refers these, and maintains a corporate memory of engagement with the Merlin subjects. Should
circumstances similar to those in Arsema’s case occur now, it would therefore fall to the MASH to review the
associated Merlin, to consult with the partner agencies, and if any issues additional to the ‘headline’ crime
were to be noted - such as the history of harassment, or the apparent age discrepancy - to convene a
meeting of partner agencies to deal with the issue. In effect, if a police focus on a future Miss Dawit would be
as the victim of a crime, the MASH focus would be on her as a child currently subject to adverse
circumstances, thus affording a further, broader quality-assuring ‘lens’ through which the totality of the
situation would be viewed, and initial oversights caught, rectified, and referred back to the relevant
department within the police or other agency to deal.
4: Remit issues
You wrote:
“According to the MPS Standard Operating Procedures at the time, the offence could not have been reported
as domestic violence as those involved were not adult and was outside the remit of the child abuse
investigation team. There appeared to be a gap, which might mean inappropriate or insufficient investigation
could be carried out.”
Response -
‘Flagging’ a crime report (by adding a code to a page on the computerised CRIS report) is the mechanism by
which crimes are brought to the attention of specialist investigative departments. For the avoidance of doubt,
difficulties in the correct ‘flagging’ of crimes for these units due to remit issues are no bar to the initial
reporting of the crime, nor to it's subsequent investigation by a competent investigator. Such difficulties
however may inadvertently limit access to the additional expertise that specialist units provide. It is important
to realise however, that ‘generalist’ investigators dealing in lieu of specialists will still be officers trained to a
suitable tevel for the task.
In line with the national standards set by the College of Policing and the Association of Chief Police Officers’
‘Professionalising Investigation Programme’ (PIP), investigative tasks are graded by Level, and assigned to
appropriately trained officers who have demonstrated their competence to deal at the relevant level through
an ‘evidence-based system focused upon intrusive assessment of practical ability and knowledge’. Within
PIP, the three levels are:
¢ Level 1 — Priority and Volume Investigations - includes ai officers whose role might involve
interviewing victims, witnesses or suspects. This includes patrol police constables and supervisors.
« Level 2— Serious and Complex Investigations - This includes C!D officers and CID supervisors, and
lead traffic officers Involved in fatal collision investigation.
e Level 3 - Senior Investigating Officers - lead investigators in cases of homicide, series stranger rape,
kidnap or crimes of complexity. Within the MPS it was agreed that this would be restricted to
Homicide SiO's within SC&01, 8, 17 and SO15,
It is impossible to be prescriptive in relation to which crimes are Level 1 and those which are Level 2, though
it is understood that Level 1, ‘the investigation of volume crime’, is typically considered appropriate to be
investigated by patrol constables and supervisors, Some instances of Actuaf Bodily Harm, the substantive
offence initially identified in the Dawit case, could fall into this category. Equally, there is no all-
encompassing definition of what constitutes a ‘serious or complex investigation’, but there is an
understanding within the service of the types of investigation that fit this category, based on experience, and
the likely skills and resource commitment required to achieve successful resolutions. Threats To Kill, the
most serious offence reported to police in the Dawit case, would be a Level 2 offence, requiring a suitably
qualified investigator to deal. In practice, Level 2 crimes are primarily investigated by Detective officers.
20/11/2014 Page 7 of 10
an,
eo,
In the Dawit case, the matter was referred to a Detective officer to deal, albeit within the ‘generalist’ main
office of CID, and with an (incorrect) assumption that the substantive offence involved was Actuai Bodily
Harm. Despite decisions made by some individuals in the case therefore, at the level of process, the remit
issue highlighted in Dawit did not impinge on the skills level of investigator allocated to deal. Clearly, though,
specialist units do ‘add value’ through their greater knowledge and experience of certain crime types, and it
is here the remit issue was relevant. Resolution of this, however, lies ultimately beyond the reach of the MPS
to address directly, as [ will now expiain.
Within the Criminal Investigation Department the remits of the specialist investigation units dealing with
Domestic Abuse (the Community Safety Units) and with offences against children (the Child Abuse
Investigation Teams) are based on a number of factors. Pre-eminent amongst these are the national
definitions for the relevant crime types, which are set by the Home Office, and are not in the gift of the police
to directly alter, although of course issues of concern can be raised with the Home Office via representations
to the National ACPO leads in the relevant area.
In relation to ‘Domestic Abuse’, the Home Office definition operative at the time of the incident set a lowest
age limit of 18 for victims. This definition was revised in 2013, and currently defines domestic abuse as:
",,,any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse
between those aged 76 or over who are, or have been, intimate partners or family members regardless
of gender or sexuality. The abuse can encompass, but is not limited to the following types of abuse:
psychological
physical
sexual
financial
emotional”
It will be noted that although the age limit has been dropped, this would still exclude Miss Dawit (aged 14 at
the time of the report and 715 at the time of her murder) from inclusion within the standard CSU remit, as
would her denials that there was any aspect of intimacy in her relationship with EEE and the fact that
he was not part of her family group.
At 14, Miss Dawit was considered a child. However, the current remit of the Child Abuse Investigation Team
is to deal with abuse of children in the following contexts:
e Intra-familial abuse (as opposed to a stranger attack) defined as “within the family and extended
family defined as aunts; uncles; cousins; siblings including step, fostered, half brother and sister,
grandparents, step grandparents, step mothers or fathers and can include long term partners but
must be an established relationship";
«- Professional abuse ~ working in a child focused environment who abuses their paid position e.g.
teachers; sports coaches; youth workers; ministers; caretaker of a schoo}; school cleaner; prison
staff;
« Other carers — who act as a carer with some responsibility for the child at the time of the offence
~@.g. babysitters; voluntary groups like scouting, unpaid sports coaches, close personal family
friends.
This list is not exhaustive and consideration is also given to new forms of abuse such as those who
facllitate chifd trafficking, exploit children sexually or use children in organised criminal activity
(cannabis farms or street theft).”
Again, it will be seen that the particular circumstances of the Dawit case, should they arise again in a
new case, would not sit easily within the usual remit of the CAIT.
Whilst this definitional remit ‘gap’ still exists, therefore, and is not directly within the power of the MPS to
alter, we have acknowledged this, and have since 2008 developed safeguards to deal with it.
Firstly, as we have seen, the additional layers of quality assurance provided to the CRIS by the Crime
Assurance Unit, and to the Merlin by the Multi Agency Safeguarding Hubs provide two additional routes
20/11/2014 Page 8 of 10
aN,
toward identifying the exceptional risk factors posed by the respective ages and relationship of the
participants here, and the seriousness of the initially overlooked offence. Secondly, we have now
instituted a ‘backstop’ procedure to be implemented in the event of a future Dawit-style uncertainty
arising regarding which unit would deal. The ‘Frequently Asked Questions’ section of the internal MPS
intranet Community Safety Unit website expresses it in the following terms:
*"Q: Does the CSU have to investigate Domestic Abuse incidents where one or more of the parties is
under 16 years old?”
“A: Though this will not be flagged as a DA incident as per MPS & ACPO policy the chances are that
all the elements are there for a DA case. The likelihood is that the perpetrator will continue to commit
further offences against this and other victims. if the case does not fall within the remit of the SCD(5)
CAIT then generally the advice is for the CSU fo investigate due to the unique nature of DA, thus
preventing further repeat victimisation and increased seriousness of incidents.” [my emphasis]
Responsibility for adjudicating in any dispute falls ultimately to the Crime Manager (Detective Chief
inspector) responsible for the Borough which ‘owns’ the crime, under National Crime Reporting Guidelines.
In conclusion on this point, therefore, ! am confident that our layered quality assurance procedures and
‘backstop’ process are now sufficient to capture and resolve any ‘remit’ difficulties which might arise from
current national crime definitions.
5: Use of interpreters
You wrote:
"There appeared to be some reluctance to use the interpreting service, so that the mother was never
interviewed.”
Response
Since 2008, routes to access immediate translation services for Initial communication with victims and
witnesses, together with arrangements to access security-checked and court-qualified interpreters for more
considered encounters such as victim and witness statement taking, suspect interviewing, or court
appearances, have been streamlined and improved. The MPS is consciously recruiting from a wider pool of
diverse language speakers, and acknowledging the spontaneous availability of the many bilingual officers
and staff we already employ. Work is in hand to use a database of these skills to improve our ability to
engage with a diverse public.
Meanwhile, dua! handset telephones in the majority of police station front offices and custody suites enable
front office staff to quickly set up three way instantaneous transtation with members of the public who are
native speakers in any language, using a commercial interpretation service, ‘Language Line’, available 24/7.
{t can also be used by sharing a single telephone if necessary, so, if required, officers and staff can
communicate with people via interpreter at their home addresses, on the street, or elsewhere, usually within
minutes of placing a request with the service. This service is usually sufficient to obtain details for an initial
crime report, and to make arrangements for more thoroughgoing interpretation if required. As discussed
above, initial training and supporting ‘Toolkits’ both highlight this service to officers and staff.
CCTV is also Increasingly being used to provide rapid ‘telepresence’ translation to some stations for lengthier
pre-planned encounters, where a centrally based interpreter can be booked to ‘attend’ stations remotely
without having to incur extended travelling times.
Finally, a centralised booking system managed by the Interpreter Deployment Team means that officers no
longer have to contact a series of possible interpreters themselves, but can call a single central number any
time of the day or night to book an attendance In person.
in short, any future failure to request suitable interpretation for a member of the public at any point from initial
encounter to court appearance will likely now be an issue for the individual officer concerned to justify, and
not for the organisation, which has taken significant steps since 2008 to provide a comprehensive and easily
accessed range of translation services for use by all of our staff.
20/41/2014 Page 9 of 10
te,
Bosn,
Conclusion
The Metropolitan Police Service endeavours always to be a learning organisation. Whilst human errors may
on occasion prevent us from delivering the quality of service we aspire to, | hope you will agree with me that
since 2008 we have made significant improvements in our business processes. The developments
highlighted here, in the areas of training and reference materials for staff, investigator accreditation, quality
assurance, supervision, and provision of support resources, will, | am sure, go a long way toward mitigating
the risk of future such incidents, of the kind the tragic case of Arsema Dawit highlighted, occurring again.
if you have any questions in relation to this letter, please do not hesitate to contact me.
Toure ev
Commander Security
20/11/2014 Page 10 of 10
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