Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0415, written 23 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Nov 2017 |
|---|---|
| Reference | 2017-0415 |
| Deceased | Michaela Haines |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire & Pembrokeshire |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: Chief Constable Dyfed-Powys Police CORONER 1 I am Jonathan Mark Layton, Senior Coroner for the coroner area of Carmarthenshire and Pembrokeshire. 2 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. 3 INVESTIGATION and INQUEST On 30th December 2016 I commenced an investigation into the death of Michaela Marie Haines who died on 23rd December 2016. The investigation concluded at the end of the inquest on 23rd November 2017. The conclusion I recorded was an open conclusion. 4 CIRCUMSTANCES OF THE DEATH (1) At approximately 02.36hrs on 23rd December 2016, police were dispatched to deal with a report of a female hanging in the stairwell of flats at Tenby Mount, Tenby. (2) A STORM (System for Tasking and Operational Resource Management) Command and Control System incident report was created and up-dated with developments as the investigation continued. (3) The STORM report identified the need to follow up enquiries with the occupants of persons living within the block of flats. It is not clear whether enquiries were followed up with the occupants of the block of flats as no record of such enquiries has been entered onto STORM. (4) The STORM report further identified that CCTV covered the stairs and would show anyone approaching the stairs. Whilst there was some evidence before the inquest that this did not operate, the STORM report was not updated to confirm the position. (5) CCTV from a local hotel was requested from the proprietors who preserved the same for police. They believe this was collected from them but it has not been entered into the property log. Had the STORM report been fully completed identifying this as a task and then recording steps taken to complete this task, then any issue as to whether this piece of evidence had been secured would have been resolved, thus avoiding the distress it caused to the family. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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 is as follows: The STORM report had not been up-dated with actions taken. This caused uncertainty as to whether outstanding enquiries had been actioned or not. This may have resulted 1 in evidence not being preserved. It could also result in work being duplicated with enquiries being made when they have already been undertaken. If the STORM report is to be used as an effective command and control document it is essential that it is updated in the light of changing developments. Training may be required to remind those using this vital work tool of the need to keep it up to date. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I 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 the 18th January 2018. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Person: Chief Constable, Dyfed Powys Police, Police Headquarters, PO BOX 99, Llangunnor, Carmarthen, SA31 2PF I 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. 9 23rd November 2017 Signed: 2
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.
Mr. Mark Collins
Prif Gwnstabl / Chief Constable
Pencadlys Heddlu Dyfed-Powys, Blwch Post 99, Llangynnwr, Caerfyrddin, SA31 2PF.
Dyfed-Powys Police Headquarters, PO Box 99, Llangunnor, Carmarthen, SA31 2PF.
• Ffôn/Tel :
• Ffacs/Fax :
• E-bost/E-mail : sharon.thomas.cmrd@dyfed-powys.pnn.police.uk
01267 226325
01267 222185
Eich cyf/Your ref :
Ein cyf/Our ref : 2-2018
Gofynnwch am/Please ask for :
Mr Mark Layton
Her Majesty’s Coroner
Dear Mr Layton
Re: Michaela Marie Haines Inquest – Regulation 28 Report
I write in response to your letter dated 23 November 2017 concerning the above matter
and sad circumstances surrounding the death of Ms Haines. I am also aware that you
have met with the Chief Constable in order to discuss this issue and of course our
meeting of last Friday at your office.
In my capacity as Head of CID for Dyfed Powys Police and on your instruction in
accordance with Regulation 28, I caused a review to be conducted by a Force Senior
Investigating Officer to explore the initial response and subsequent investigation. I am
also aware of the Human Rights Article 2 Ruling On Engagement report, which I have
read in pursuance of this review and letter.
Following the completion of the review I am firmly of the belief that there are no
suspicious circumstances. The investigation concerning the events of the evening shows
no evidence of third party involvement. However, it apparent that the recent separation
from her boyfriend was causing Ms Haines some distress and I support your view that it
was a cry for help which tragically resulted in her death.
I note and agree with your observations in relation to the inconsistent endorsement of
the Police STORM log resulting in confusion in respect of officer in command,
management / allocation of actions and their subsequent endorsement which did impact
on the effective recovery and collection of CCTV. However, in light of these
shortcomings, there was sufficient evidence elsewhere including CCTV to show no third
party involvement which supports the Open Conclusion at the Inquest.
As a
Y Wobr Brydeinig am
Wasanaeth o Safon
The National Award
For Quality of Service
Prif Gwnstabl • Mr. Mark Collins • Chief Constable
Mae Heddlu Dyfed-Powys yn croesawu
Gohebiaeth yn y Gymraeg neu’r Saesneg.
consequence of the review, eight
Buddsoddwyr
Mewn Pobl
Dyfed-Powys Police welcomes
Correspondance in either Welsh or English.
Investors in
People
recommendations were identified which are currently subject to implementation and
include:
Review and amendment of Sudden Death Policy confirming officer in command
and method to record enquiries
STORM log will not be closed until investigation is complete or transfer to
alternative system to record enquiries
Clear decision and rationale outlining determination of investigation
All raised actions be recorded numerically
In drafting this letter and causing a review it is my intention to provide you with
reassurance that the matters raised are being addressed, and more importantly, to
confirm with the family that there is no third party involvement.
I cannot adequately express my sympathy for the family of Ms Haines and would
willingly and sensitively be prepared to meet them and explain the process and findings
of this review, if indeed they would find that helpful.
Yours sincerely
Shane Williams
Det Chief Superintendent
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