Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0235, written 19 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jul 2018 |
|---|---|
| Reference | 2018-0235 |
| Deceased | Jeroen Ensink |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Jeroen ENSINK (died 29.12.15)
THIS REPORT IS BEING SENT TO:
1. Deputy Assistant Commissioner Richard Martin
Metropolitan Police Service
6th Floor, New Scotland Yard
Victoria Embankment
London SW1A 2JL
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 30 December 2015, one of my assistant coroners, Jacqueline
Devonish, commenced an investigation into the death of Jeroen Ensink,
aged 41 years. The investigation concluded at the end of the inquest on
17 July 2018.
The jury made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Dr Ensink was stabbed to death in a wholly unprovoked attack.
Following a guilty plea,
was convicted of
manslaughter by way of diminished responsibility, and a hospital order
was made.
was diagnosed with paranoid schizophrenia.
1
had been arrested seven months earlier for possession of a
bladed article and assault on a police constable. He was granted police
bail and given a long bail date because he intended to return to Nigeria.
However, he stayed in Nigeria longer than anticipated and so failed to
answer his bail on 25 August 2015. Instead, his sister attended Holborn
Police Station with a letter from his doctor in Nigeria describing mental ill
health including paranoia and hallucinations.
He was arrested at Heathrow upon his return to the UK on 11 October
2015, and was granted bail by Highbury Coroner Magistrates, with
conditions including surrendering his passport and reporting to a police
station every day.
The CPS (Crown Prosecution Service) later made a decision to
discontinue the prosecution, a decision that they reviewed after Dr
Ensink’s death and considered was wrong.
However, if the right decision had been made, at that point the only
material difference would have been that
would have had to
continue reporting to a police station each morning after 23 December
2015 (his last reporting day) and until the trial on 5 January 2016.
In the event, Dr Ensink was stabbed on 29 December 2015.
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.
1. Following his arrest on 22 May 2015, no officer created a Merlin
in respect of
, though his behaviour suggested to both
arresting officers the possibility that he was suffering mental
health or substance abuse problems. Thus the MASH (multi
agency safeguarding hub) was never alerted to his potential need
for treatment.
2. Police officers at the scene of
arrest took a
statement in support of the prosecution of the offence of
possession of a bladed article in a public place. However, they
missed out a line from the statement that the CPS considered was
location when he had the
vital to demonstrating
knife. This omission was rectified only months later.
2
3. Only one statement was taken, though there were other witnesses
on scene.
4. The custody sergeant who booked
into custody
recorded that
had threatened police officers with a
knife, though there was no mention of this on the CRIS (crime
record information system) report or in the officers’ statements,
and both officers gave evidence at inquest that
had
not had a bladed article in his possession when they arrested him.
This was later found on the windowsill through which he had
climbed into the property.
5. The custody sergeant noted that
had a bruised,
bleeding and swollen lip, yet to the custody record question
regarding any injuries, he recorded no.
6. The arresting officers described in evidence a violent struggle with
when they arrested him. He had tried to grab the
Taser belonging to one of the officers. Yet the custody sergeant
recorded that no force had been used. And this was despite the
fact he said that he was under the impression that
had
wielded a knife against the officers. He said in evidence this was
because the force had been used outside the police station.
7. Both arresting officers formed the view that
was
suffering mental health or substance abuse problems, and both
included these two factors in their statements, but the custody
sergeant gave evidence that no mental health concerns were
brought to his attention.
8. Consequently, no mental health concerns were brought to the
attention of the FME (forensic medical examiner) who examined
, meaning that his mental state examination was more
superficial than it would otherwise have been.
9. Both arresting officers thought there was a possibility that
was under the influence of cannabis. The custody
sergeant recorded this as heavy cannabis use, he said because
in his experience people who use cannabis use it heavily.
10. The custody sergeant gave evidence that, had it not been for
suspected cannabis use, he would not have called the FME for
any other reason.
11. When
sister rang the police station to explain that in
Nigeria, her brother had been diagnosed with mental health
problems, and to ask that she be permitted to attend during his
interview as an appropriate adult, the detention officer recorded
this, but the system did not create any sort of alert or pop up.
3
12. Neither custody sergeant working that night read the note of the
conversation recorded by the detention officer in the detention log.
13. Consequently, the FME was never alerted to this, and so did not
return to re-examine
.
14. The booking in custody sergeant recorded authorisation of a strip
search, but did not record the result of the search.
15. The interviewing officer did not read the CRIS report, and gave
evidence that it was not MPS protocol so to do. The CRIS report
contained a record of the question mark over
mental
health.
16. The interviewing officer was surprised when
denied
possession of a bladed article in a public place but volunteered
possession of a hammer. As a consequence of his surprise, he
asked very few questions about this and did not pursue it.
17. The PNC (police national computer) was never flagged with a
warning that
had mental health problems, either after
his arrest, after his sister’s phone call, or after the letter from his
Nigerian doctor was presented and scanned onto COPA (case
overview and prosecutions application); and was never flagged
with a warning that he had assaulted a police officer.
18. There was no common understanding among police officers of
who should look where, when, for what: the PNC, the Merlins, the
CRIS, the COPA, the detention log, the custody record risk
assessments etc.
19. There was an almost total lack of understanding among police
the CPS Notice of Proposed
officers of
Discontinuance procedure, most particularly in terms of who this
should go to, who should send it, what actions are then possible
and what impact these actions might have.
the detail of
It did not seem to me that there was one defining moment in the months
leading up to Dr Ensink’s death, but rather there were many apparently
inconsequential moments. Errors or omissions may seem small at the
time, but each – both individually and cumulatively – represents a missed
opportunity that has the potential for devastating consequences.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
4
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 17 September 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 following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Ms Alison Saunders, Director of Public Prosecutions
, wife of Jeroen Ensink
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
19.07.18
5
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