Faiza Ahmed

DEPARTMENT FOR WORK AND PENSIONS

RESPONSE TO REGULATION 28 PREVENTION OF
FUTURE DEATHS REPORT ON FAISA HASSAN AHMED

Introduction

This report fulfils the Department for Work and Pensions’ duty to respond to a
Prevention of Future Deaths report made under the Coroner's (Investigations)
Regulations 2013. This request has arisen following an inquest which reported on 20
January 2016 into the death of Faisa Hassan Ahmed. Ms Hassan Ahmed was a
former claimant of Jobseeker’s Allowance, who took her own life on 7 November
2014.

The Department takes seriously any declarations of intention to attempt suicide or
self harm that are made by its customers and has put in place a well-designed
process that seeks to ensure appropriate action is taken. There is a clear, detailed
six point action plan that staff must follow if a customer declares an intention to kill or
harm themselves. In addition, DWP provides both guidance and training to help staff
deal with these incidents. The policy, procedures and guidance are reviewed
regularly to ensure that they continue to meet their objectives and to identify areas
for improvement.

This report is structured in three parts. The first describes the current system for
managing threats to attempt suicide and or self harm. The second provides a
summary of the circumstances in Ms Hassan Ahmed's case. The final part describes
what systems the Department has in place continuously to improve its processes to
support those who threaten to attempt suicide and self harm, including how it deals
with the consequential impact this may have on DWP staff.

The current process for managing threats to attempt suicide or self
harm

The Department deals with a wide range of customers who at some point in their
lives may be vulnerable because of life events or disability. Providing the right level
of support to enable these customers to access DWP benefits and use DWP
services is a major commitment. To this end the Department has agreed a common
definition of vulnerability as being any ‘individual who is identified as having complex
needs and/or requires additional support to enable them to access DWP benefits
and use our services’. This ensures consistency and continuity in the delivery of our
services to those who are vulnerable. The Department's staff are trained to
recognise the signs of vulnerability and to respond appropriately. This policy includes

~ ensuring the Department's staff are vigilant to customers who may directly declare,
or whose behaviour indicates, an intention to attempt suicide or self harm.

Extract from DWP national guidance for all staff:

‘Managers, in all DWP businesses who work with customers, must use the
Departmental National Six Point Plan framework to develop arrangements that suit
their own local working environments to help staff deal effectively and safely with
customer declarations of intention to attempt suicide and self harm.’

The Department's staff are not medically trained. Therefore it is important that there
are systems, procedures and responses in place to provide support to staff in the
event that a customer says they intend to harm themselves. Consequently,
managers throughout DWP are expected to develop arrangements with staff that
comply with the principles of the DWP Six Point Plan framework and to produce their
own localised Six Point Plan. A copy of the Department's guidance which includes
the Six Point Plan Framework is attached at Annex A. The locally developed version
for Poplar Jobcentre where Ms Hassan Ahmed claimed JSA has also been attached
at Annex B.

The Six Point Plan
In brief, the Six Point Plan framework is as follows;

1. Take the statement to self harm or suicide seriously — remain calm and listen
carefully.

2. Summon a colleague — to act as a support partner.

3. Gather information - to gauge level of risk.

4. Provide referral advice — if situation is non-urgent, e.g. general distress but no
immediate plans or means to attempt suicide or self harm.

5. Summon Emergency help — if customer is distressed, at serious risk or in
immediate danger.

6. Review — discuss incident with line manager and record

The arrangements which are put in place will be as comprehensive as possible to
reflect different interactions with our customers, whether through face to face
communications, telephone calls or written correspondence from customers
(including emails). These support arrangements also extend to members of staff who
work away from the office, including those who visit customers in their homes.

Once the Six Point Plan is in place for the individual office, the Department's
managers will ensure that staff regularly refresh their knowledge of processes and
procedures and have the capability to know how to respond appropriately to
situations arising. This level of awareness includes access to both detailed guidance
and formalised training to help staff gain and refresh their knowledge.

Ms Hassan Ahmed’s Case

Faisa Hassan Ahmed was due to attend Poplar Jobcentre on 4 November 2014 to
make her declaration of unemployment in order to remain eligible for her benefit
payment. However, she contacted the Jobcentre that day to say she was sick.

Faisa subsequently attended the Jobcentre on 7 November 2014 where she
explained to the Work Coach that she had not come in on 4 November because she
was ill. She was asked to complete a form to formally declare her sickness on 4
November.

Faisa completed and returned the form to the Work Coach, then immediately left.
This meant that the Work Coach was also unable to discuss the detail of the
statement she had made; ’! was busy trying to kill myself, drinking non-stop’. On the
form Faisa stated the period of iliness had occurred between 4 and 7 November.

The Work Coach discussed his concerns with his line manager, invoked the Six
Point Plan, and recorded the incident in accordance with DWP procedures. DWP
policies state that its employees are empowered to take any reasonable steps,
including contacting the emergency services, if they feel the customer faces clear
and significant risks to their welfare or safety. In this case, based on the information
he had, the Work Coach made a judgement that there was no immediate risk to her
safety. The information available to the Work Coach at that point was based on the
form that Faisa had completed, stating a period of illness between 4 and 7
November which was now ended, and the fact that she had attended the Jobcentre
to make her declaration to receive her benefit. Sadly, Faisa died at Westferry station
later that same day.

Reviewing the Processes

As with any public facing organisation, it is always possible that DWP staff may
encounter customers who might say they intend to harm or kill themselves. This can
also be a distressing experience for DWP staff and their other customers. So it is
important that staff know how to manage such an event to reduce distress and
achieve an outcome where everyone is safe.

We expect staff to be alert to customers who may directly declare, or whose
behaviour indicates, an intention to attempt suicide or self harm and to be aware of
the Six Point Plan and to use this as a basis to enable them to manage situations
that may arise effectively.

This localised Six Point Plan must be developed then regularly reviewed in
consultation with the Department's Trade Union representatives to ensure it
continues to meet its objectives and for continuous improvement purposes. Staff
awareness is further underpinned with bespoke learning to support them when
dealing with all vulnerable customers. An example of how this learning supports

3

:
° Po

raising the awareness of customers threatening suicide and/ or self harm is attached
at Annex C. This is drawn from one of our national learning products - Supporting
Customers With A Vulnerability.

At a national level, the policy and guidance are reviewed regularly to ensure they
continue to meet their objectives and for continuous improvement purposes. DWP
uses a variety of internal communication channels to ensure staff remain aware of all
changes to its guidance and processes as they occur.

Conclusion

The situation that has given rise to the requirement for this response is extremely
sad and our condolences and sympathies go out to Ms Hassan Ahmed’s family for
their loss.

Nevertheless, in this case we feel that the Departmental processes around
managing the threat of suicide and/ or self harm were followed both diligently and
correctly. In recognition of the risk, DWP staff took the necessary steps to invoke the
agreed processes that would manage the risk appropriately. Importantly this action
was based on the evidence that staff were presented with. It is not our view that any
opportunity to engage with any other organisations was missed.

As the information we have set out in preceding paragraphs shows, the
Department's approach to managing threats to attempt suicide and self harm is
under continual review and development and we do treat them seriously. Such .
internal mechanisms provide a valuable method of refining the processes being
applied as well as helping to identify opportunities for improving supporting products
like those of learning and development which help to build staff capability.

Therefore as part of this continued review, we will now be taking the opportunity to
issue a reminder to all DWP staff about the guidance related to suicidal ideation that
has been described in this report.

*

London Ambulance Service INHS|

NHS Trust

Executive Office

Ms ME Hassell Headquarters
Senior Coroner 220 Waterloo Road
Inner North London London
St Pancras Coroners Court SE18SD
Camley Street i
London
N1C 4PP

Your Ref :

Our Ref : INQ/10363/14
Date : 11 March 2016

Dear Ms Hassell
Regulation 28: Report to Prevent Future Deaths-Faiza Hassan Ahmed

Thank you of your Regulation 28 Report to Prevent Future Deaths dated 20 January 2016,
bringing to my attention matters of concern encompassed within the jury’s determination.

The Trust can confirm the Emergency Medical Dispatcher (EMD) noted on the call log that
the patient “wanted to die”, thereby indicating her suicidal intent, but this particular piece of
information was not conveyed to the crew. Unfortunately, this was an individual error and all
EMDs are trained to tag and pass pertinent information to the attending crew. However, the
information which the crew were given was “Psychiatric/Abnormal behaviour/Suicide attempt;
Trying to slit wrists; Armed with a weapon-glass;” therefore the crew were given adequate
information of Faiza’s suicidal intent.

Since the incident the crew involved undertook Reflective Learning and a Clinical Update
was published in April 2015 reinforcing the assessment of Capacity. This was disclosed at
the Inquest in the evidence about the Serious Incident Report and the actions arising from
the incident.

On 7 September 2015 a new Operational Management Structure was implemented which
introduced a Stakeholder Engagement Manager role for each sector of London. This role
consists of liaising closely with other stakeholders, including the Metropolitan Police to
discuss issues of wider concern for that particular Borough. Issues of concern can include
frequent callers, community events, and resident issues.

In addition, a new role of Quality Assurance & Governance Manager has been implemented
in every sector. Part of this role is to process and develop specific Care Plans for Category 4
patients. These patients are those with an underlying medical condition and in need of a
different/alternative care plan than the wider public.

Furthermore, the LAS have allocated funding for Mental Health Nurses to work in the control
room. Currently the Trust has filled 4.5 posts and has an on-going recruitment to fill a further
1.5 posts within the next 6 months. Their role is to provide a telephone assessment from
speaking with the patients and provide advice to crews on scene. In addition the Mental
Health nurses are skilled at referring patients directly to crisis teams or appropriate pathways
for patients with mental health needs.

| hope this reply is helpful in explaining the actions taken to address the matters of concern.
In closing | wish to offer my condolences to Miss Ahmed’s family.

Yours sincerely,

Dr Fionna Moore .
Chief Executive London Ambulance Service NHS Trust

idence TOTAL POLICING

DIRECTORATE OF PROFESSIONALISM

Coroner ME Hassell, Deputy Assistant Commissioner
St Pancras Coroner's Court,
Camley Street Room 918
London New Scotland Yard
N1C 4PP Broadway
Tel: 0208 387 4882 London
SW1H OBG

Email:  met.police.uk
By Email to: 7
Legal Clerk to

Date: 17th March 2016

Dear Ms. Hassell,

| write on behalf of the Metropolitan Police Service in response to your Regulation 28 Report
to prevent future deaths dated 20th January 2016. This was prepared following the inquest
into the death on the 7th November 2014 of Ms Faiza Hassan Ahmed, which was opened on
11th November 2014 and concluded before you and a jury on 20th January 2016, at St
Pancras Coroner's Court.

Background

You will recall that the proximate cause of death was injuries sustained by Faiza Ahmed
stepping in front of a train, following contact in the two days prior to her death with the
Metropolitan Police Service (MPS), the London Ambulance Service (LAS) and the Poplar
Job Centre. You concluded that she killed herself.

Matter of Concern
You stated that:
“... The matters of concern are encompassed within the jury's determination...”

We note that the jury gave a narrative verdict, commenting on a number of aspects of the
case pertinent to parties in contact with Ms Ahmed prior to her death. | will confine myself to
consideration of those points directly or indirectly concerning the Metropolitan Police. If |
may excerpt these from the narrative:

1. “On the morning of 6 November 2014, Faiza reported that a man had attempted to
rape her in her home. The historical and continuing lack of rapport between Faiza
and the police contributed to her not receiving the support she needed following
this incident.”

2. “The period of time elapsing between the sexual offences investigative techniques
(SOIT) officer's first and second attempt to make contact with Faiza meant that
she never received specialist support from the Sapphire Unit.”

3. [on 7th November 2014 Faiza made two declarations of suicidal intent, to a Job
Centre, and to the London Ambulance Service via a 999 call. Police were informed
of only of the second of these, and attended] “...lack of rapport between Faiza
and the police officers and LAS crew on the scene hampered the provision of
support to her. Two SOIT officers arrived shortly after the police and LAS, but did
not see Faiza.” :

4, “The information they had about the previous day's report of attempted rape was
not adequately conveyed to the police response team and was not conveyed at all
to the LAS crew. This left both insufficiently informed to fit their response to Faiza’s
needs,”

5. “Throughout the two days, information held on police databases about Faiza's
history of vulnerability was not relayed to any of the police and LAS personnel who
dealt with her, again leaving them insufficiently informed to fit their response to
Faiza’s needs.”

MPS Response - Preface

In drafting a response to these points the relevant subject area experts have been consulted.
These include: Detective Superintendent ii Sexual Offences
Exploitation & Child Abuse Command; with Chief Inspector [EE Professional

Standards Champion for EJ Met CC (Central Communications Command, responsible
for call handling); with Chief Inspector of the Territorial Policing Mental Health
Team; and Detective Inspector responsible for the MPS National

Mental Health Policing Portfolio.

| have also drawn on the findings of ‘Operation Indigo’, the internal Metropolitan Police
Specialist Investigations review into the events; and the findings of three further documents,
all of which we believe you have had prior sight of.

The first of these, the ‘independent Review into The Investigation and Prosecution of Rape
in London’, was commissioned by Sir Berard Hogan-Howe, the MPS Commissioner, in
May 2014 and undertaken by Dame Elish Angiolini DBE QC. The report of the review was
published in April 2015, and made 46 specific recommendations, both for the MPS, and for
the Crown Prosecution Service, designed to improve the service provided, from initial
investigation through to offender prosecution, to victims in all cases of sexual offences.

As | believe you are aware, at the time of Ms Ahmed's death in November 2014 the
structural concerns Identified In the Angiolini Review had all been accepted and were already
being addressed in some depth through the ongoing work outlined in the second document
of relevgnee here, the Joint Crown Prosecution Service/MPS Response to Dame Angiolini's
Review~.

' https://www.cps.gov.uk/Publications/equality/vaw/dame_elish_anglolin|_rape_review_2015.pdf
? https:/Awww.cps.gov.uk/london/assets/uploads/files/dame_elish_joint_response.pdf

These recommendations have in turn fed into the ongoing work of the third document
referred to here, the Joint National Rape Action Plan, initlated on 6" June 2014, and
likewise, published in April 2015.°

The following is based on a review of these documents, and other relevant sources, by
Detective Sergeant Directorate of Professional Standards Organisational
Learning (EE The above subject area experts have, In turn, reviewed this response.
Neither I nor those consulted have had sight of transcripts of any oral evidence from the
inquest itself, so in the event of any variance between reported facts and evidence you know
to have been presented during the inquest itself, | defer to your knowledge.

Dates, relevant parties and communications have, where possible, been confirmed by
reference to emails, minutes of meetings, published policies, intranet communications or
other documents.

The details of the poor rapport reported between Faiza Ahmed and the police, and issues of
information sharing between the police and the other agencies concerned were explored
during the inquest itself. Many of these issues were particular to the facts in this case, rather
than offering general insight pertinent to systemic practices of the wider organisation, and I
do not therefore propose to revisit them in great detail here.

It is significant to note that the broad thrust of the jury's criticisms might be summarised as
two complementary Issues; communication between relevant parties of prior knowledge
regarding Ms Ahmed’s situation; and the difficulties attending officers had in achieving useful
rapport with Ms Ahmed.

Concern Response: Points 1 & 3 above, rapport; point 2, SOIT engagement

To deal with the issue of rapport first: it is important to acknowledge that factors other than
the abilities of the particular officers in attendance to Ms Ahmed in her final days may have
had a role in this. For example, her previous troubled personal history of contact with police
has been widely reported in the press‘. This history may have influenced her willingness to
engage on these final occasions. The findings of the intemal police investigation, Operation
Indigo, bear out some of the difficulties encountered, whilst at the same time making it clear
that attending officers in the final encounters indeed attempted on each occasion to achieve
meaningful contact, albeit with a person who undoubtedly presented a challenge to rapport-
building.

For example, the Operation Indigo author describes police response to the initial allegation
of sexual assault made by Ms Ahmed, on Thursday 6" November 2014, the day before her
death. (para 4.2.21-23) PC [EEE one of the first-responding officers, on encountering
Ms Ahmed outside her address, noticed blood on her clothing, and, quite properly, attempted
to persuade her to allow police to seize the clothing for forensic examination, and to
dissuade her from immediately returning to her home, the apparent crime scene. Both of

3 http://www.cps.gov.uk/publications/equality/vaw/rape_action_plan_april_2015.pdf

* e.g http:/Awww.theguardian.com/uk-news/201 6/feb/06/falza-ahmed-cries-for-help-missed-every-authority-
simon-hattenstone?CMP=Share_lOSApp_Other

these measures were best-practice steps designed to advance effective investigation. It is
acknowledged however that a third party witness®, commenting on the exchanges In which
the officer attempted to obtain a clearer picture of what had actually occurred, nevertheless
expressed ‘surprise’ at the intrusiveness of the questioning, conducted by a male officer with
Ms Ahmed in a public area; a less than ideal situation. The guidance document ‘Rape and
serious sexual assault - First Responder — checklist’, available for reference for our officers
24/7 via the MPS intranet, advises instead:

*,.. [taking a victim] to a comfortable and private waiting area .”

The witness added that, although the officers’ questions were not in any way inappropriate,
and the officers had explained to Ms Ahmed why they needed to ask them, she would
herself have felt ‘uncomfortable’ answering such questions, in such a way. (para 4.1.12).
The initial questioning itself however was in line with best practice. Sufficient details must be
obtained to understand what is being alleged, where and when it has occurred, and who the
principal parties are.

Meanwhile the second initial attending officer, PCIE sought advice, via local line
management, from the on-call specialist ‘Sapphire’ Central Sexual Offences Investigation
Team Detective Sergeant, DS EEE regarding how best to proceed with the agitated
Ms Ahmed, who informed the officers that she had been drinking throughout the preceding
night. In line with current best practice, PC EE a (female) Sexual Offences
Investigation Trained (‘SOIT’) officer, was tasked by DS EEE with attending Ms Ahmed.

It was clear that there was some tension between the desire on the part of the initial
attending response officers to achieve best evidence, and the manner and location of the
communication between Ms Ahmed and those officers, necessitated by the character of the
contact between the parties. Despite these difficulties, however, it is worth noting that a
degree of initial rapport was nevertheless established, to the extent that the attending
officers obtained sufficient detail of the alleged offence and offender to circulate a description
of the suspect, who was then promptly arrested by colleagues nearby.

In light of the evident difficulties at the scene it was initially proposed by DS EN that
the meeting with the specialist SOIT officer would be at Limehouse Police Station, which was
equipped with a ‘Comfort Suite’. Comfort suites are dedicated rooms within police stations
where victims of rape and sexual assault can talk to police in privacy and comfort. It is
accepted that some areas within police stations may appear uninviting or intimidating for
victims, so these comfort suites have been designed as comfortable and private places to
help put victims at ease when reporting these offences.

As the venue for the sexual offences specialist to obtain a more detailed account was to be a
police station, it was also initially felt that a single officer could safely deal. PC

prepared to make her way, without her personal protective equipment (‘PPE’ - stab proof
vest, baton, handcuffs, CS spray).

As the Indigo report goes on, however:
HD stato (vis Anmed] walked off towards her flat and he followed trying
fo prevent her from entering. Once outside the address he and PC[ tried to

5 a neighbour, enlisted by the officers in an attempt to overcome Ms Ahmed's verbal hostility toward them

explain to her why the scene needed to be preserved but she continued to be
obstructive.

He stated Faizae continued to demand that she be allowed to enter her flat and
threatened to kick her own door down. Eventually she used her keys to enter the
address and closed the door on the officers. PC MEstatec that he left the
scene after she had entered her address.” [ibid., para 4.2.22]

DS BB received the information that Ms Ahmed was no longer cooperating with
officers at the scene. Research had also indicated Ms Ahmed was capable of being volatile
and violent when intoxicated. Reports for example indicated she had assaulted police in her
home five months earlier when they had attended there to check on her welfare.

Based on the information he had available, therefore, DS Hace a dynamic risk
assessment that a meeting with Ms Ahmed in her present state of mind was no longer

’ suitable for an immediate single SOIT deployment, and instead arranged for PCO
re-attend Ms Ahmed’s address with a colleague the following day, Friday 7" November. This
decision was thus directly responsible for the initial delay in the assigned specialist, female
SOIT officer making contact with Ms Ahmed, which was commented on adversely by the jury
at point (2) above.

Was this a reasonable decision, in the light of all the circumstances? The so-called ‘Golden
Hour principal of investigation rightly emphasises the importance of prompt evidence
preservation, ‘fast time’ enquiries etcetera, undertaken in the immediate aftermath of a
reported incident. However, we also train all our officers in the National Decision Model®, a
cognitive tool designed to offer a coherent structure for explaining what was done during any
incident and why, for use both at the time by practitioners, and subsequently, as an
evaluation tool for examiners of the decisions made. One arm of this model is explicitly
dedicated to risk:

‘Assess threat and risk and develop a working strategy’.

Applying this model to the decision made by DS as the responsible supervisor,
then: It is apparent he had to consider, not only physical risk to his officers, but also practical
threats to the developing investigation. Thus elements to be considered would include the
fact that PCE did not have her Personal Protective Equipment with her, (an admitted
oversight which the officer has since been spoken to about); but also that she would in any
case at that time have been a solo officer attempting to deal with a demonstrably recalcitrant
victim who had, by her own account, been steadily drinking for some considerable time prior
to police arrival; one moreover with a documented history of aggressive behaviour toward
police. These factors would have to be weighed alongside the fact that Ms Ahmed, in
returning to her flat and excluding police from it against advice had already potentially
compromised scene preservation; whilst other officers responding to the call, acting on the
basis of the minimal information then available, had taken positive steps to arrest the
suspect for the offence. So, some aspects of the investigation as a whole were moving
forward; an immediate threat to the victim had been addressed; whilst other elements were
already potentially compromised; and the difficulties encountered in achieving immediate
rapport with the victim were now known.

®° https:/Awww.app.college. pollce.uk/app-content/natlonal-decision-model/the-national-decision-model/

Guidance on judging the rapid decision making often required of police officers in difficult
circumstances such as these notes that attention should be paid to the quality of the decision
making, (which is within the control of the police), not the outcome, (which is not). In this
case, the chief element of risk, the suspect, was for the moment eliminated. Other matters to
some extent had been taken out of police hands through Ms Ahmed’s own refusal to
engage, possibly exacerbated by alcohol, which might also impact on her abllity to provide a
detailed statement immediately. In this context, the decision to delay the SOIT contact until
she might prove more tractable to a recovery of rapport, to have recovered from her night's
drinking, and the officer safety aspect covered by sufficient control measures (the
deployment of second officer, availability of correct PPE) to mitigate physical risks can
therefore be seen to be a rational one.

Unfortunately, as other uniformed officers responding the following day to Ms Ahmed's
separate call to London Ambulance Service threatening self harm found, the passage of time
had not wrought the hoped-for change in Ms Ahmed’s demeanour. [Ibid. paras 4.13.4-9]:

“On arrival the front door to number 22 was closed so [PCE Knocked

’ several times before a female voice from within said “Who is it?” He replied “It's the
police. Can you open the door please?” The female replied “Everything Is fine. There
is no crime here”. He said “Can you open the door as | don’t want fo force it open.
We just need fo speak with you that’s all.”

The door was opened by a female fater identified as Faiza Ahmed. She said “I don't
need you lot. You can fuck off.”

PCT stated that he explained they were asked to attend on behalf of the London
Ambulance Service as they had been contacted by someone threatening to harm
themselves with a piece of broken glass.

Faiza Ahmed replied “Well it's not me. | don’t need you lot here. | never asked you to
come so can you please fuck off.” He replied “Have you hurt yourself with some
glass?” She replied “No”. He said “What's your name?” and she replied “You don't
need to know my name it's all on your systems.”

PCE stated that he saw a letter and a bank card on the sofa which confirmed her
name as Faiza Ahmed.

He stated he said “Have you called for an ambulance?” and she replied “No. | don't
need an ambulance and | don’t know why you are here”. He said “Could anybody
else have called an ambulance for you? Have you phoned a friend or anybody to say
you were going to hurt yourself with some glass?” She replied “No. Look | never
called you lot please fuck off.”

The Indigo report recounts how PC[iiiicontinued to attempt to persuade Ms Ahmed to
allow the officers into the premises, to engage with her regarding her mental state and
medical treatment, and to conduct what risk assessment he could of her mental capacity,
physical health, and levels of risk presented by her state of mind, evidence of alcohol
drinking and her immediate environment. [paras 4.13.10-15] He then continued to remain on
scene whilst the ambulance crew arrived, and took over the lead in the continuing attempts
to rapport-build, only for the LAS personnel to experience similar difficulties. [para 4.13.16]

It was during this period also that the Sexual Offences Investigation Trained officer PC

HEfand a colleague attended, having postponed their initial planned visit from the
previous day, after Ms Ahmed's initial refusal to engage, and the resultant dynamic risk
assessment conducted by DS IE On this second occasion too, having been briefed
by PC i regarding Ms Ahmed's state of mind and volatility, and by the LAS regarding
her nevertheless evident mental ‘capacity’ and lack of immediate welfare concems, all
parties once again decided to leave. [para 4.13.20]

It is acknowledged that no officer present claims to have briefed the LAS crew regarding the
details of the alleged sexual assault call from the previous - ‘ay 4.13.21]. In fact, the
only officers capable of doing this would have been PC ind her colleague, as at this
point the uniformed response officers were themselves unaware of the earlier call. This was
arguably regrettable, as knowledge of the circumstances may have gone some way to
explaining Ms Ahmed’s eariler call and attitude toward the proffered assistance on this
second occasion. It is by no means clear however what difference, If any, this knowledge
would have made to the practical options open on this second visit to either police or
ambulance personnel. PC Mand her colleague for example did have this background
Information; but it did not alter their operational decision to withdraw without speaking to Ms
Ahmed. : ‘

Of perhaps more consequence, was the decision these professionals collectively agreed
upon regarding Ms Ahmed's mental ‘capacity’, since this sets definite limits on the ability of
state agents such as the police and medical staff to intervene In a person's private life
against their will.

The concept is defined at Section 2(1) of the Mental Health Act 2005:

“,..@ person lacks capacity in relation to a matter if at the material time he is unable to
make a decision for himself in relation to the matter because of an impairment of, or a
disturbance in, the functioning of the mind or brain.”

Section 3 of the same Act elaborates upon the nature of the relevant test:

“3(1) For the purposes of section 2, a person is unable to make a decision for himself
if he is unable —

(a) to understand the information relevant to the decision,

(b) to retain that information,

(c) to use or weigh that information as part of the process of making the
decision, or

(d) to communicate his decision (whether by talking, using sign language or
any other means).”

Responding to concerns regarding the limits of police action in an earlier case involving a
vulnerable adult”, Chief Inspector Territorial Policing Mental Health Team gave
consideration to the limits of police action when dealing with persons who may be suffering
from mental illness or some other temporary or permanent reduction In their ‘mental
capacity’, but who have otherwise committed no offences. Police powers in these situations

7 Inquest of Finnutla Catherine Martin, 19/11/14

are governed chiefly by elements of two Acts; Section 136 of the Mental Health Act 1983,
and the Mental Capacity Act 2005. Regarding Section 136, CIMhotes:

“IThis] only gives officers powers to detain persons in public, [my emphasis] and in
‘immediate need of care and control’, a high threshold; whilst powers to detain
persons in private places, deemed by on-scene qualified mental health professionals
to be ‘in need of immediate care and control’, can only be engaged via a warrant
obtained under Section 136 of the same act.”

More recently the Mental Capacity Act 2005 gives officers some limited protections from
liability should an individual officer, at the time of an incident, feel that ‘restraint’ (which
encompasses both physical restraint and, for example, preventing a person leaving a
particular place) is the only option to prevent a person from committing an immediate civil
wrong or criminal act; but otherwise expressly confers no powers on police to deprive a
person of their liberty, as the decision in Sessay v South London and Maudsley NHS Trust
and Commissioner of Police for the Metropolis ([2011] EWHC 2617 QB) made clear.

The relevant thresholds were in any case not engaged on either of the occasions Ms Ahmed
encountered police in her final days. She was presenting as a victim of crime, albeit a
vulnerable one, not as a person suffering such derangement of mind that she required
‘immediate care and control’ which would engage police powers. She therefore was entitled
to refuse to engage with police, and the officers had no power to force themselves upon her. .

Similarly, whilst the case of Osman v UK® imposes positive obligations on police to take
action in certain circumstances where they have knowledge of a risk of harm existing, recent
case law has likewise reaffirmed that police owe no general duty of care to members of the
public’, nor to victims of crime’°. There appeared on the face of it at the time of the second
visit nothing in Ms Ahmed’s attitude toward police, nor the circumstances in which she was
found, to engage an immediate duty of care. She had apparently made threats to self harm
earlier, and there was evidence she had been drinking, which may have led to some
temporary diminishment of her capacity, but it is clear from the reports of her words and
actions on both occasions that she still retained sufficient ‘capacity’ to pass the test set by
the legislation, that is, to understand her situation, and to make decisions about it which she
did indeed communicate — forcefully ~ to the officers present. Nor was there anything in her
immediate behaviour or surroundings to suggest that she was at imminent risk. The option
for her to self-refer via the LAS and A&E to mental health support was available, but not
exercised.

Thus, despite the call which had prompted their attendance, at the time of the second police
interaction with Ms Ahmed, her clearly stated and unequivocal rejection of the aid offered,
together with an absence of any observable, immediate intention to harm herself which might
otherwise have mitigated against her apparent capacity, makes it difficult to see what more
officers could or should have done within the law, even if they had possessed perfect
knowledge of her previous history and recent allegation. She was under no obligation to
engage with the officers if she did not wish to. It follows from this that the question of rapport
becomes somewhat moot at the point Ms Ahmed clearly stated her wish to see the police
depart.

: (1998) 29 EHRR 245
009: Michael v The Chief Constable of South Wales Police [2015] UKSC 2
Brooks v Commissioner of Police for the Metropolis and others 2005, [2005] UKHL 24

Chief InspectomEEERgain:

“Police powers of any sort to deal with a Mental Health incident within a private
address are limited. The recent Dept of Health/Home Office review of Sections 135 &
136 of the Mental Health Act has resulted in Parliament choosing not to provide police
officers with any specific power by which they could support people suffering from
Mental Health illness within a private dwelling... This makes voluntary attendance to
an A&E a reasonable and viable alternative for persons in distress. We must
remember that people frequently do self admit to A&E when struggling with Mental
Health, as Mental Health Services are often difficult to access, especially out of hours.
We must also remember that the London Ambulance Service's own pathway into
mental health services is via an A&E. LAS do not have any direct pathways into a
Mental Health Place of Safety.”

Concerns re points 4 & 5 above: Information available and shared

This brings us to the second strand of the Jury's criticism, the lack of information sharing
regarding Ms Ahmed's history between police colleagues, and between police and LAS at
the scene.

Firstly, it is important to recognise that the totality of information available to police in dealing
with vulnerable persons is greater now than it was in 2014. A key part of this is the
Vulnerability Assessment Framework (VAF), introduced to the MPS in January 2014, and
rolled out across the following year to the whole frontline officer workforce through regular
training days.

This is a cognitive tool designed to support our frontline first-responding staff, deliberately
designed to extend officer awareness of potential ‘vulnerability’ in a subject group, from
those narrowly captured within, for example, the terms of the Mental Health Act, to aif
persons coming into contact with police.

The intention is to assist MPS police and staff in recognising any such vulnerability,
temporary or permanent, occasioned by any source at the earliest stage of any contact;
then to maximise opportunities for referral to other agencies for early intervention, to prevent
a vulnerable person becoming a victim or suspect at a later stage. ‘Vulnerability’ is
understood therefore to be potentially present in the moment of any initial contact, and may
arise from permanent mental or physical impairments, temporary adverse reactions to
prescribed medications; substance abuse; mental health issues; or transitory emotional
distress. The officer may or may not know what the cause is, and such knowledge may or
may not assist in the present situation. Regardless of cause, the emphasis is on recognising
effects, and then dealing appropriately with those. The VAF outlines five key factors - the
‘ABCDE’ - that must be considered when assessing individuals that police have contact with.
These are:-

e Appearance
e Behaviour

e Communication/capacity

e Danger (caused or exposed to)
e Environment/circumstances.

If three or more of these factors give cause for concem, consideration using professional
judgment should then be given to whether an appropriate protective safeguarding pathway is
required. Where three out of the five VAF areas are identified, then a ‘Merlin’ database entry
for a 'Vulnerable Adult’ must also be created as a minimum, and a safeguarding response
documented. These details must also be captured on the crime recording system ‘CRIS’, if a
crime is alleged.

The officer will also be encouraged to adopt a ‘CARES'"' approach at the scene:
“C ontain the situation - rather than restrain.
A pproach within view of person. Avoid approaching from behind.
R educe distractions - helmet off, turn radio down, one officer talking.
E xplain what you are doing (simple language) and listen to the person.

S low down your actions and give the person more space. Seek the help of a relative
or Carer.”

It is also necessary to recognise however, that adults with evident capacity are entitled to
make ‘lifestyle choices’ without state interference, even if these are, objectively considered,
bad ones. Considered in Isolation, individual instances of such behaviour may or may not
warrant the creation of a ‘Vulnerable Adult’ entry on the [iidatabase (officers always
have discretion to record an entry, even if less than three of the ‘ABCDE’ factors are present
at a single encounter, if in their professional opinion, an entry is warranted.) The intention is
that over time, police will, through this mechanism, naturally build a searchable ‘corporate
memory’ of contacts with vulnerable persons, or persons whose vulnerable behaviours have
brought them into contact with the police. This history also then provides the basis for
tracking the diversion of such people to organisations better equipped to meet their needs
than the police. These options, however are for the most part ‘slow time’ actions, that Is, for
after-the-event consideration, within the secondary stages of investigation.

However, at the time of an encounter, this type of in-depth intelligence, whilst accessible
directly to any officer making their own enquiry (in preparation for a pre-planned visit, for
example, or, as DS EEE demonstrated, in undertaking his risk assessment) would not
have been automatically provided to first responders. These officers are tasked in ‘fast time’
in response to calls received by the MPS Command and Control Center, MetCC. In both of
the two final encounters with Ms Ahmed, it was uniformed patrol officer first responders who
were initially seeking to build rapport with her, reliant in the first instance on the necessarily
more limited ‘deployment intelligence’ provided for officers in their role. As Chief Inspector
Professional Standards Champion at Met CC explains:

“The provision of intelligence and the Service Level Agreement that had been agreed
with [Met Police] business groups at that time was that [MetCC] would provide
‘deployment intelligence only’ that is, primarily officer safety information, unless the

"' Source: Phase 1 Officer Safety Training Lesson Plan, ‘Safety In Mind’ Mental Health DVD input, created
10.02.15

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call concerned ‘ absent’ children or a limited number of other pre-identified ‘high risk’
categories of calls, for example, firearms or extended response domestic abuse calls ,
which attract an enhanced level of background intelligence enquiries,

in 2015 this process was reviewed as part of the ‘New Way of Working’ and was
cemented within that document. Between August and October 2015 1300 Met CC
staff were briefed on the provision of ‘deployment intelligence’, and as a result, in
excess of 40,000 more deployments have since been made where officers have
received actionable intelligence before Time Of Arrival on scene. This is an
improvement in the timeliness of our provision of deployment intelligence, but it is
important fo understand the constraints under which this ‘fast time’ intelligence
research must take place.

For the information to be most useful, it must be obtained and made available to the
responding officers between the time of the receipt of the call, and the arrival of
officers on scene at it. We aim to arrive on scene at an ‘Immediate’ (I- grade) call
within 15 minutes 90% of the time. We aim for an S (‘Soon’) grade response time of
within 60 minutes 90% of the time.

To cope with the volume of emergency calls received within the limits of staff available
to field those calls, our call handlers therefore must deal with each call within an
average of 371 seconds. In November 2074 intelligence for all Computer Aided
Despatch reports (CADs, the typed location and incident-type records used to
document assigned units and capture outcomes) was provided by a centralised
intelligence function split between Lambeth and Bow MetCC centres. This is now
based entirely at MetCC Lambeth.

Intelligence checks are conducted on all | and S grade calls and added to the working
CADs. if relevant the despatcher will then alert officers at the scene. MetCC
operators are trained to provide deployment intelligence for Officer Safety issues only.
At the time of this incident, the information that Ms Ahmed had called the previous day
would have been available to the despatcher because the caller's number and other
details would have been highlighted on the CAD screen. If the despatcher had
clicked on one of the highlighted headings, the previous days’ deployment would have
been visible to them. It would be best practice for this to be done, but it is not
mandatory, nor always practicable. As Ms Ahmed did not show any known officer
Safety concerns from the previous day's call, despite this information being available
on other MPS intelligence systems relating to visits on other earlier occasions, no
additional intelligence would have been provided via this route.

Fast-time Intelligence checks however are now conducted using the
through which a single query will search the separate
databases. The search is conducted using
data input by the operator, a drop down menu for officer safety risk and a key words

search relating to officer safety. Officers use the mnemonic ‘0 structure the Hi
searches: Py a index and T-

Telephone numbers. PNC checks are also done separately, if names and dates of
birth are known.

Despite the ‘quick overview’ this search provides, limitations within our current search
functionality means that the only way to be sure of gathering all relevant data on a

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venue, victims, suspects etcetera is to read each of potentially very many information
reports, Police National Computer records, Merlin entries, Crime reports, custody
records and so on in detail. Since each one of these record types could run to many
pages, this task is clearly not capable of being undertaken within the minutes or
seconds available to assist our first responders.

Given these time strictures it remains beyond the current capability and capacity of
MetCC SCO37 to provide a failsafe, all encompassing intelligence function for first
responding officers. The expectation therefore must be that the focus of ‘deployment
intelligence’ remains high risk officer safety intelligence.

Officers at the scene of an incident must continue to conduct their own dynamic risk
assessments, investigate the incident and apply professional judgement to their
decision making process This may then include them seeking ‘further and better
particulars’ through local colleagues conducting more detailed research on our
systems, either via radio from the scene to their local ‘Grip & Pace’ borough
intelligence support if available (though not all ‘Grip & Pace’ intelligence functions are
Staffed 24/7); or later, in person, when time and circumstances permit.”

In short, to answer the concem regarding information sharing; at the time of the first incident,
the initial responding officers had no automatic method of accessing the historical
information available to an in-depth manual interrogation of our systems; and officers at the
second call would likewise not have been automatically alerted to the existence of the call
the day before. In both cases the attending officers would have had to initiate their own
requests, if they felt they needed further background Information. It was not practicable then,
nor is it now, to provide full disclosure to initial attending officers of all possible intelligence
relevant to the venues and parties they deal with, which may be held within the greater
police intelligence structure, within the time frame of an emergency response.

Moreover, the question must again be considered: even if this information had been
available, what practical difference could it have made to the officer's handling of the
incident, given Ms Ahmed’s clearly stated rejection on both occasions of police involvement?
Steps were still being taken to progress the enquiry from the suspect side; had Ms Ahmed
lived, further low-key overtures by a SOIT officer would have doubtless been made to
engage with her, outside of the inherent drama and potential conflict of an emergency
uniformed response. Unfortunately, this was not to be.

In conclusion

Faced with the (all too common) dilemmas ralsed by ‘crisis’ Interactions with variously
vulnerable people, the lesson the MPS has taken from such cases in our training and
support of front line officers is to foreground a victim-centered approach, as discussed
above. In sum, this means:

e Ensuring that our officers and staff receive appropriate training and support in
engaging with vulnerable persons (e.g. VAF, CARES)

e Ensuring our frontline officers and staff receive appropriate advice on initial
reporting of sexual offences - via 24/7 intranet access to best practice guides &
expert on-call specialists

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y

e Reviewing our protocols for the deployment of Sexual Offence trained specialists

e Reviewing the management and sharing of information from our call handlers to
our response officers; as in the ‘New Way of Working’ discussed above; and
between the MPS and our partner agencies, via such initiatives as the MPS/LAS
Memorandum of Understanding, and other multi-agency fora.

The concerns raised here regarding police interaction with Ms Ahmed are also closely
echoed in the thematic groupings of the MPS response to the Angiolini Review, already
under way at the time of this incident, which similarly addresses:

e The service provided to victims

e Supporting our practitioners

e Accountability and continuous improvement
e Legislative change

Common to Dame Angiolini’s critique, our response to it, and the Joint National Rape Action
Plan is the recognition that the past several years has seen some success by the Police and
the Crown Prosecution Service nationally in encouraging the reporting of sexual assault. In
the same period London has also seen increasing diversity in and growth of its’ population.
The consequence of these elements combined is a concomitant increase in the workload of
the specialist ‘Sapphire’ units tasked with investigating sexual offences, which are amongst
the most technically demanding officers deal with, as the Angiolini review notes:

“With a population in excess of 8 million, London’s size and geography make unique
demands on policing. it is also by far the most ethnically and culturally diverse city in
the United Kingdom, a diversity that is reflected in the profile of complainants and
Suspects who the police encounter when investigating cases of rape. The rise in the
number of reports of rape year on year present the police with an enormous challenge
in London, especially given the complexities of investigating rape, a challenge which
is not made any easier by overstretched resources.”

[Review., para 5, p. 10]

Commissioner Sir Bemard Hogan-Howe acknowledges that these pressures have required a
reconsideration of the police response, including within the ‘Sapphire’ units, and he has
committed to providing the resources to make this possible:

“| accept that there is an acute need for increased capacity and capability on the
Sapphire teams and | will ensure that the future structure and resourcing model is
designed to meet the demands of increased reporting levels and promotes a working
environment that is caring and supportive of Its officers. Linked in to this is my
commitment to invest in training to ensure that first responders and investigators are
equipped with the tools they need to perform their roles to the highest standard.”

[Response, p.10]

There is also acceptance that the police cannot undertake this work alone; a large number of
the recommendations in the Angiolini and National Plan recommendations address improved
criminal justice practices, to be led by the Crown Prosecution Service. There is also a

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recognition at initial investigation level of the value of the ‘Haven’ Sexual Assault Referral
Centres run jointly by the MPS with the NHS. The aspiration here is to expand and enhance
the role of Havens in their key tasks of capturing best early evidence, and in supporting

victims.

It sadly must remain unknown what level of rapport our specialist sexual offence
investigators might have been able to achieve with Ms Ahmed, had she lived to engage with

them.

We must acknowledge however that even with an enhanced fast time intelligence capability,
and our improved training of frontline officers in dealing with vulnerable persons, we are stil!
bound by law to respect the autonomy of any innocent member of the public demonstrating
sufficient capacity to decide not to engage with us, even If they have previously sought our
aid. Through training and technology we can maximise the likelihood that rapport will be
established and a working alliance established, and even, where other sources of evidence
exist, and it is in the public interest to do so, pursue ‘victimless’ prosecutions. But we can
never guarantee that rapport will be established with all victims in all circumstances.

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