Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0178, written 13 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jun 2018 |
|---|---|
| Reference | 2018-0178 |
| Deceased | Keiron Bould |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| 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.
i REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Constable of Warwickshire Police Chief Constable of West Midlands Police National Police Chiefs’ Council 1 CORONER | am Louise Hunt Senior Coroner for Birmingham and Solihull 2 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. 3 INVESTIGATION and INQUEST On 06/11/2017 | commenced an investigation into the death of Keiron Christopher Bould. The investigation concluded at the end of an inquest on 12th June 2018. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH The deceased left his home address at 17.30 on 17/09/17 to smoke cannabis. He had an argument with his girlfriend earlier in the day and had taken her morphine tablets. He drove to a car park at the bottom of Ryecroft Close in Chelmsley Wood where he was seen in his parked vehicle at 21.45. His vehicle remained in the same position with him sat in the driving seat, being seen by two dog walkers in the area several times until he was found still in the driving seat at 16.16 on 18/09/17. He last used his mobile phone when he read a text at 22.52 on 17/09/17. He likely took the morphine overdose around 12 midnight. His phone was not working at the time. Paramedics attended and he was taken to Birmingham Heartlands Hospital where he was pronounced deceased at 17.30. He was reported as a missing person to police just after midnight on 18/09/17. The incident was initially dealt with by Warwickshire police who the transferred the case by email to West Midlands Police at 01.53. The following morning police made further inquiries but were unable to locate Keiron before he was found by others. Following a post mortem the medical cause of death was determined to be: MORPHINE OVERDOSE 5 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. — 4. When each force received a missing person report soon after 12 midnight on 18/09/17, there was no communication about who would take primacy of the inquiry. There should be a system in place to ensure verbal communication confirms who is dealing with any incident. 2. When Warwickshire police decided to transfer the case to West Midlands police an email was sent at 01.53 to a generic email address. There was a 4 hour delay in this email being picked up and actioned. There should be a system in place to ensure verbal commination about a transfer so the receiving force is aware of the referral. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 August 2018. |, 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 sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Mr Bould’s family an 1am 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. 13/06/2018 Signature. Louise Hunt Senior Coroner Birmingham and Solihull
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.
ge Warwickshire 3? POLICE Our Ref: MJ/AT/2018 Your Ref: 121143/Imb Martin Jelley QPM Chief Constable Mrs Louise Hunt Force Executive Team Senior Coroner, Warwickshire Justice Centre Birmingham and Solihull Coroner’s Court Newbold Terrace 50 Newton Street LEAMINGTON SPA Birmingham CV32 4EL B4 6NE 1 Tel: ee Date: 6'" August 2018 Dear Mrs Hunt, Response to the Report to Prevent Future Deaths — arising from the Inquest into the death of Kieron Bould. Thank you for your letter of 13 June 2018 enclosing your Report to Prevent Future Deaths in the above matter. | note the matters you raise as concerns, and would say at the outset that we acknowledge that there were issues with the communication between Warwickshire Police and West Midlands Police at the initial stages of the police involvement in this tragic case. However we also note that, based on your findings that the evidence indicates it is likely that Mr Bould took the morphine overdose at around midnight — shortly before the time he was reported missing to both forces — the matters giving rise to concern in this case would not appear to have affected the outcome in relation to Mr Bould. Mr Bould was reported missing to Warwickshire Police by his mother at 00.41 on 18 September 2017. | | stated that her son actually stayed a lot of the time with his partner, giving an address within the West Midlands Police area. At 00:19 West Midlands Police had also received a call from his girlfriend reporting Mr Bould as missing. Warwickshire Police immediately graded this matter as a high risk missing person and began immediate enquiries in relation to Mr Bould’s vehicle. At 00.46.58 Warwickshire Police passed the information to West Midlands Police via a telephone call and a subsequent follow up email with all details from all logs up to the time of 00.49. Following further enquiries by Warwickshire Police, including an exchange between Warwickshire and West Midlands confirming that given the known history as presented by his mother, Mr Bould was being treated as a high risk case, at 00.56 Call Handler Laura BARNES from Warwickshire Police Control room advises on the log that an email has been sent to West Midlands Police with all the details of our enquiries POLICE NON-EMERGENCY @ 101 a EMERGENCY ALWAYS. CALL 999 www.warwickshire.police.uk WV @warkspolice Fi warwickshire police so far. At this stage, it is also recorded that we were given a different email address to send the detail to by West Midlands Police control room. it later transpired that the email address which West Midlands Police provided to Warwickshire Police specifically for the use of communication between Forces in relation to Mr Bould was a generic email address which was not regularly monitored. Warwickshire Police were unaware of this fact and therefore used the email address provided for updates on this matter, including the transfer of primacy to West Midlands Police at 01:53 once it had been established by PC Mitchell from Warwickshire Police that both his mother and his girlfriend had confirmed that Mr Bould did reside within the West Midlands Police area and had gone missing from their area. Warwickshire Police were unaware at the time that the email address provided would not be regutarly monitored for communications. We had made telephone calls to West Midlands at the outset of this matter, however once we had a West Midlands Police incident number and an email address was provided to us by West Midlands for the purpose of sending them updates, we utilised that system. Having leamt that West Midlands system is different to the Warwickshire system (where call handlers have a separate screen to monitor emails as well as a system showing the calls and incidents logs) changes were made to our policies and procedures as detailed in the witness statement of Chief Inspector Kent from Warwickshire Police and West Mercia Police, including the need for telephone contact with the other force in respect of transfer of primacy. These changes were implemented in February 2018. Matter of concern 1 “There should be a system in place to ensure verbal communication confirms who is dealing with any incident” in the initial stages following the call from Mr Bould’s mother, Warwickshire Police did make telephone contact with West Midlands. At 00.46.58, the Warwickshire log confirms that information was passed to West Midlands Police via a telephone cail and subsequent follow up email with all details from all logs up to the time of 00.49. At this stage, West Midlands provide Warwickshire with a different email address to send the detail to West Midlands Police contro! room. This is the generic email address referred to previously. At 00.59.11 there is a further telephone call recorded between Warwickshire Call Handler fF and West Midlands Police to clarify where Kieron lives. At 01.00.43 West Midlands say that they believe Warwickshire Police should take ownership as their understanding is that Kieron’s partner states she does not live with her, but that he lives with his mother in Warwickshire. They have not gone to Mb address yet (Mr Bould’s girlfriend). They are passing the incident to a Sergeant to review. Therefore, at 01.02.01 Warwickshire Police confirm that we will send officers to travel over to Mr Bould’s partner's address in West Midlands to speak with her. At 01.47 PC Mitchell confirms that all parties state that Mr Bould lived with his girlfriend on West Midlands Police area. There is a comment on the incident that this is to be passed back to West Midlands for them to deal with and then close down the Warwickshire Police incident. This was because Mr Bould had been staying in and had gone missing within the West Midlands Police area and therefore, from an operational police perspective, the officers who are closest to where Mr Bould was last seen were West Midlands’ officers — as such they were the right force to lead the enquiries to trace him. At 01:53 Warwickshire Police call handler confirms this information to West Midlands Police in an email sent to the email address provided to us for that purpose. itcan be seen therefore, that at 00:59 Warwickshire Police did make telephone contact with West Midlands in respect of confirming who should best deal with this case. There was confusion as to which Police area Mr Bould lived within, and therefore Warwickshire confirmed that we would make further enquiries, including travelling to the West Midlands police area to do so. Ideally, there would have been further telephone contact at this stage, although between 01.00 and 01.47, it was clear that Warwickshire Police were leading on establishing where Mr Bould had been living (whilst also conducting further missing person enquiries). In this particular case, it seems the difficulties arose with the transfer of primacy at 01:53. Matter of concern 2 “There should be a system in place to ensure verbal communication about a transfer so the receiving force is aware of the referral” Initially in this case, there was telephone contact between the Warwickshire Police control room and the West Midlands Police control room. However, following Warwickshire Police’s visits to both Mr Bould’s mother and girlfriend to confirm his home address, the critical communication confirming Warwickshire Police’s transfer of primacy to West Midlands at 01:53 hours was communicated only by email. Previously our call handlers were required to satisfy themselves that the information has been delivered and received. Arguably, in this case, the call handler would state that he had sent the required information to the email address specifically provided for this purpose. However it has been recognised that this resulted in a 4 hour delay in this case and therefore the changes recommended in your report have already been incorporated into the procedures now undertaken by Warwickshire Police call handlers when transferring matters between Forces. Whilst previously there was no requirement to follow up a transfer with a telephone call, it was widely adopted good practice to do so. As a result of this case alerting us to the risks of not being required to make a follow up telephone call, on the 7" February 2018, Chief Inspector Kent directed an addition to the working practice guidance and task book for call handlers, that if the report of a missing person is to be directed to another force a follow up telephone call shall always be made to confirm receipt of the information before a log is closed down. Therefore, the action recommended by you has already been implemented by Warwickshire Police in order to attempt to mitigate the risks identified in this case. In addition, we are aware of the response you have received from Chief Constable Thornton on behalf of the NPCC and would clarify that the College of Policing Approved Professional Practice (APP) direction around ownership of missing people has been re-circulated to our Control Room Management, supervisors and staff to remind them of what should be done to provide clarity on ownership of missing persons enquiries, and the importance of that ownership. If you require any further detail in respect of these matters, we would be happy to assist further. Yours sincerely _ Chief Constable Martin Jelley
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.