Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0278, written 15 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2015 |
|---|---|
| Reference | 2015-0278 |
| Deceased | Paul Kalnins |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Commissioner of the Metropolis, c/o Directorate of Legal Services, 1* Floor, Victoria Block, New Scotland Yard, 8-10 Broadway, SW1H 0BG CORONER | am Nadia Persaud, Senior Coroner for the Eastern Area of Greater London CORONER’S LEGAL POWERS | 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. http:/ legislation.gov.uk/uksi/2013/1629/part/7/m: ~ | INVESTIGATION and INQUEST The investigation into the death of PAULS RICARDS KALNINS commenced on the 9" July 2014 and concluded on Friday 10" July 2015. The inquest concluded with a conclusion of suicide. CIRCUMSTANCES OF THE DEATH Mr Kalnins, who was aged 19 at the time of his death, had a history of depression. His mental state deteriorated significantly in May 2014. On the 31 May 2014 he went missing from home and he was reported to the police as a missing person. He returned of his own volition on the 2"° June 2014. After his return, he was very withdrawn. An incident occurred, whereby he lay in the road in the early hours of the 23 June 2014, resulted in him being taken to Newham General Hospital. On this occasion he complained of hearing voices telling him to harm himself. He left the hospital before assessment and he was reported missing by his mother later that day. On the 5" July 2014, Mr Kalnins was spoken to by 4 police officers on routine patrol. He was found sitting under an underpass. Checks of the PNC revealed he had been reported as a missing person and had discharged himself from hospital. Further checks through the support channel were made and the officer requested further information be provided, from the Merlin database. The communications officer did not identify any concerns about Mr Kalnins’ mental health and he could not locate a telephone number for Mr Kalnins’ next of kin. The Merlin database did contain the next of kin’s telephone number and also the fact that his mother was concerned that Mr Kalnins might harm himself, due to his mental state. When the officers returned to the station some hours later, to update the Merlin database, they found the additional information. Attempts were made to return to Mr Kalnins. Unfortunately, Mr Kalnins, had left the location and could not be found. The following day, he was found hanging in a shed to the rear of Foresters apartments in Barking, Essex. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. 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 communications officer confirmed that he had worked in his role for 15 years, but had had little need to obtain data from the Merlin database. Whilst he therefore had access to it, he was not familiar with it. He confirmed that he had last had training in 2011, in relation to the database. (2) The communications officer said that he did not know where to look for the required details. He explained that the database is complex to navigate. The front screen does not contain any key information relating to risk. (3) An investigation was carried out by the Directorate of Professional Standards and they found that the communications officer had accessed the correct pages of the Merlin database but had failed to see the relevant pieces of information. (4) The line manager for the communications officer concerned, confirmed that it would “100% assist if key risks come up automatically on the front screen of the Merlin database”. (5) She confirmed that the communications officers are under a lot of pressure when they provide information to officers on the ground; they do not need to access the Merlin database regularly and have to go through a lot of detail in the database. She agreed that refresher training for communications officers would also be useful. (6) The investigator from the Directorate of Professional Standards, [EEE a!so agreed that the Merlin database is a piece of software which could be improved and could be more user-friendly. He agreed that Merlin is an important database and it would be useful to have refresher training. (7)It was considered that the identification of the grade of risk (low, medium or high) on the front page, together with a brief explanation as to the type of risk posed, is likely to assist in prompting the communications officer to undertake a more detailed search of key parts of the database. [INI suggested that the warning could be in red. Having heard all of the above evidence, | consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future. Mandatory refresher training for communications officers, may also reduce risk. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by, 9 September 2015. |, 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. 8 | COPIES and PUBLICATION | have sent a _ of my report to the Chief Coroner and to the mother of the deceased | am also under a duty to send the Chief Coroner a copy of your response. | will also forward a copy of your response sh 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. 9 | 15 July 2015 [SIGNED BY CORONER] ins
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.
Uae TOTAL POLICING DIRECTORATE OF PROFESSIONALISM Fiona Taylor Senior Coroner Nadia Persaud, Deputy Assistant Commissioner The Coroners Court Queens Road Room 918 Walthamstow E17 8QP New Scotland Yard Broadway London SW1H OBG Our ref: IX-540-14 Date: 9th September 2015 Dear Ms Persaud, | write on behalf of the Metropolitan Police Service in response to your Regulation 28 report to prevent future deaths, dated 15th July 2015. This was prepared following the inquest into the death of Pauls Ricards Kalnins, heard on 9th and 10th July 2015. Mr Kalnins was initially reported as a missing person, seen alive by police on 5th July 2014 and subsequently found hanging in a shed to the rear of Foresters Apartments, Barking Essex on 6th July 2014. You will recall that the finding of the inquest was suicide. Matters of Concern In your ‘Matters of Concern’ comments you reviewed the communication officer’s evidence of his unfamiliarity with the system, its reported complexity, and the issue of refresher training, before concluding: 1."! consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future.” 2."Mandatory refresher training for communications officers may also reduce the risk." MPS Response - Preface In drafting a response to these points, subject area experts have been consulted, principally: e lan Cox and Richard Gittings, of HQ Digital Policing, under the ultimate command of Commander Alison Newcomb, Business lead owner for the Merlin database system; e Chief Inspector Paul O'Herlihy, Chief Inspector -Professional Standards & Continuous Improvement Standards & Capability Unit, Central Communications Command (MET CC), responsible for communications staff. Dates, relevant parties, and communications have, where possible, been confirmed by reference to emails, meeting minutes, published policies, intranet communications or other documents. The following is based on a review of such documents. The above parties have, in turn, reviewed this response. | have not had sight of transcripts of any oral evidence from the inquest itself, so in the event of any variance between these reported facts and evidence you know to have been presented during the inquest itself, | of course defer to your greater knowledge. Response Concern #1: Highlighting Risks on the front screen of Merlin HE statics that if information is correctly input onto the system in the first place, the suggested functionality is already present on the system, and would result in a red warning triangle being prominently visible on the top right of every page of the database entry. Clicking on this triangle takes one directly to the relevant warning text. An internal briefing document with screen shots taken from Mr Kalnins’ real Merlin record has been prepared to illustrate this, but as this contains sensitive personal data.which should not be circulated to third parties without permission, It has not been included here. If you wish to have sight of this document, please advise, and we will facilitate this separately. The document has been viewed by Detective Sergeant PF my Organisational Learning Manager and she confirms that it illustrates the process by which the Warning Signal alert is invoked when creating or updating a record, by selecting from a clickable drop down list of Warning Signals, which can be used to highlight any issues explored more discursively in the free text ‘DETS’ entries. As Mr Gittings states at point #6 of his briefing note: “This addresses the recommendations of the Coroner, but as with any IT system, it depends on users inputting information correctly.” In short, individual operator error might be said to be an issue in this aspect of the case, but that error lay principally in the omission of the original inputting officer, in failing to select the appropriate warning flag to accompany and highlight the free text information found in the relevant ‘DETS’ entry. Had an appropriate flag been selected at the point of entry creation - ‘Mental’ [health], ‘Suicidal’ and ‘Self Harm’ are three examples of the selection available, from a longer drop down list — then the front page, and every other page of the report viewed by the communications officer would have born the unmistakeable and very visible red triangle ‘road sign’ graphic icon containing an exclamation mark in the top right corner of every page of the record, offering a direct, clickable link to the relevant information. In relation to this area of concern, the Metropolitan Police Service does not intend to make changes to the Merlin database because the functionality identified already exists. However, the importance of this functionality will be part of the training that is set out below, with an intended completion date of 31 March 2016. Response Concern #2: Refresher Training It nevertheless remains true that an operator who was more experienced with the Merlin database than the communications officer in this case, may have thought to check the DETs entries in case any vital information was missing. This, and the evidence given at inquest by both the communications officer and the DPS investigator, EE regarding the relative lack of ‘user friendliness’ in the Merlin system, suggests that more could be done to improve the knowledge of our communications staff in regards to the system. This need has become more pressing since January this year, when Merlin was adapted to provide the central repository of non-criminal information about adult ‘Vulnerable Persons’ coming to the notice of police. This includes information regarding police knowledge of a person's previous mental health history. With this in mind and in direct response to this recommendation, Chief Inspector O’Herlihy contacted all line managers for the affected staff as set out below on the 12th August 2015. This was on the instructions of Operations Superintendent at MET CC a “The recommendation for Met CC was to accept that mandatory refresher training for communications officers on the Merlin database may reduce the risk. J fully accepted this and asked that a plan be developed to deliver this training. The training is delivered via [computer based training] NCALT over three modules and takes a couple of hours...a completion date of 31st March 2016 , has been set to allow for a final compliance check at. the yearly Performance Development Review point... | have suggested that priority should be given to the staff not trained, with the opportunity to refresh understanding for staff who are... can | ask you to ensure that line managers are aware of this requirement and that training is monitored at each centre to ensure 100% compliance, by 31st March 2016.” The intention therefore is that by 31st March 2016, all current staff at MET CC will have had recent refresher training, incorporating both the importance of the ‘red flag’ marker and the possibility that there may be important detail contained in the incident reports not flagged by it. The completion of this training will be checked at an individual’s annual performance review to ensure compliance. In Conclusion | trust the measures taken above reassure you that we have responded fully and promptly to the points you have raised arising from this tragic incident. vlurs acu, jona lor Deputy istant Commissioner
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