Prevention of Future Deaths reports · 2017

Ozeivo Akerele

Regulation 28 report to prevent future deaths, reference 2017-0337, written 19 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report19 Jul 2017
Reference2017-0337
DeceasedOzeivo Akerele
CoronerSean McGovern
Coroner areaCoventry
CategoryPolice related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Coventry Coroners  

MR S MCGOVERN 
SENIOR CORONER 

Coroner’s Office, Manor House, Coventry.  CV1 2ND 
Telephone 02476 833345 Email coroners@coventry.gov.uk 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

THIS REPORT IS BEING SENT TO: 

  Chief Constable  - West Midlands Police 

CORONER  

1 

I am S McGovern, senior coroner, for the coroner area of Coventry 

CORONER’S LEGAL POWERS  

2 

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. 

INVESTIGATION and INQUEST  

3 

On 25 April 2016 I commenced an investigation into the death of Ozeivo Andrew AKERELE. 
The investigation concluded at the end of the inquest on 1 November 2016. The conclusion 
of the inquest was a Misadventure (Copy attached). 

CIRCUMSTANCES OF THE DEATH  

4 

See attached Record of Inquest 

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. 

5 

The MATTERS OF CONCERN are as follows.  –  

 
 
 
 
  
  
  
  
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 (1) failure to find the body of Mr Akerele despite an intensive search when in fact his body 
was found very close to the last confirmed sighting of him. 

(2) failure to search the disused graveyard at or about the time of his disappearance. where 
Mr Akerele was eventually discovered 15 months later by children.- the graveyard was only a 
few metres away from the last sighting of him on CCTV on 31 January 2015. 

(2) failure of the search team to find Mr Akerele when they did eventually search the disused 
graveyard in approximately late February 2015 despite the graveyard being approximately 
60m x 30m. 

(3) The recommendation by 

 for a more thorough search was not followed up. 

(4)The Police Search Advisor was unaware of the recommendation for a more thorough 
search by 

(5) The Police Search Advisor was unaware of the (cursory) nature of the search of the 
graveyard in February 2015  

ACTION SHOULD BE TAKEN  

6 

In my opinion action should be taken to prevent future deaths and I believe you as Chief 
Executive of the Trust have the power to take such action.  

YOUR RESPONSE  

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 19th July  2017. I, the coroner, may extend the period. 

7 

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  

I have sent a copy of my report to the Chief Coroner and to the following Interested Person - 
Mrs Akerele  (mother) 

I am also under a duty to send the Chief Coroner a copy of your response.  

8 

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. 

8 November 2016  

9 

Re-dated 19 July 2017 (as previous Report appears not to have been sent)      

Senior Coroner S McGovern

Responses

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.

Response from West Midland Police (PDF)
POLICE HEADQUARTERS

CHRISTOPHER JOHNSON Lloyd House
ASSISTANT CHIEF CONSTABLE PO Box 52
(OPERATIONS) Colmore Circus Queensway
BIRMINGHAM
West Midlands
B4 6NQ
Mr S McGovern Direct Telephone:
Senior Coroner ewer
Coroner’s Office ,
Manor House
Coventry
CV1 2ND
12'" September 2018

Ref: 722/2016.Akerele

Dear Mr McGovern,

| write in reference to your letter dated 20/07/17, touching on the death of Ozeivo Andrew
Akerele, who went missing on 31/01/15.

In your letter you provided the outcome of the inquest as death by misadventure and using your
legal powers you raised concerns regarding the police search under paragraph 7, Schedule 5, of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

As you will be aware, matters arising from this incident were referred to the Independent Office
for Police Conduct (IOPC) and it was not appropriate to comment whilst the matter was still under
investigation. The IOPC investigation has now concluded and we received their written response
on 07/09/18. The outcome of the IOPC investigation is as follows:

1) No criminal case to answer.

2) No requirement to refer the matter to the Crown Prosecution Service (CPS).
3) No formal recommendations.

The Appropriate Authority in our Professional Standards Department (PSD), FC
has since reviewed the IOPC decision to assess whether the officer’s conduct is capable of
amounting to gross misconduct or misconduct subject to s.23(6)(a)(i) Schedule 3 of the Police
Reform Act 2002. The outcome of this review is that no further action will be taken.

Under Paragraph 28(1)(b) of Schedule 3 of the Police Reform Act 2002, a ::
responded to the IOPC outlining opportunities for organisational learning.

In relation to the searching, it does appear that a more comprehensive search strategy and
updates could have been compiled, with absolute clarity around who had searched what area, to
what extent and at what time. The individual decisions by and HE 2ppcar
reasonable, but a more comprehensive effort would have ensured that the relevant information

that had accessed the land that [IEE ouch inaccessible, and the relative

limitations of the search that ae: carried Out, would have been more apparent at an
earlier stage. It also appears that an earlier invitation to the POLSA may have assisted in the
tasking and recording of searches at the earliest opportunity.

Preventing crime, protecting the public and helping those in need
www.west-midlands.police.uk

The case will now be referred to the National Missing Persons Operational Group to consider
working with the Police Search Advisor (POLSA) to amend guidance around how a search is co-
ordinated in similar cases; specifically providing clarity around the tasking of the search, what is
being searched for and the accurate recording of search, completed with oversight by Senior
Investigating Officer (SIO) and POLSA.

| trust that this response assists with your investigation and | would like to apologise for the time
that it has taken in responding. | would like to thank you for the extensions that you have granted
to allow for this matter to be thoroughly reviewed by the IOPC and PSD.

If you require any further information, please do not hesitate to contact me.

Yours sincerely,

Chris Johnson
ACC Operations

Related reports

Other reports by Sean McGovern

See all →

More reports categorised “Police related deaths”

See all →

Track Police related deaths

See every Prevention of Future Deaths report matching Police related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.