Rosario Cordero-Sanz

DIRECTORATE OF PROFESSIONALISM 

Ms Mary Hassell, 
Senior Coroner, 
Inner North London 
St Pancras Coroner’s Court, 
Camley Street, 
London, N1C 4PP 

Tel.: 020 7974 4545 

Richard Martin 
Deputy Assistant Commissioner 
6th Floor 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email: R
Tel: 020 7230 1417 

Your ref:  
Our ref: IX/52/18 & 1901_02 

Date: 22nd January 2019 

Dear Ms Hassell, 

I am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (MPS). 
I write in response to your Regulation 28 Report to Prevent Future Deaths dated 29th October 2018.  
Your report was sent following the conclusion of the inquest into the death of Ms Rosario Cordero-
Sanz. 

In  drafting  our  response  we  have  consulted  with  the  relevant  subject  matter  experts,  principally: 
, Citizens in Policing Metropolitan Special Constabulary (MSC) - Continuous Policing 
Inspector 
Improvement,  Detective  Constable 
,  Directorate  of  Professional  Standards’  Specialist 
,  Head of  Support Met  Command &  Control  (Met  CC)  and  Inspector 
Investigations; 

, Central East Borough Command Unit (CE BCU).  

Response to Matters of Concern 

1.  MPS special police officers are not issued with tablets as regular officers are, yet the three 
on duty who attended on Friday night/ Saturday morning were given one of the police vans 
that  is  not  equipped  with  an  on  board  computer.  This  meant  that  they  could  not  check 
details on police computer systems themselves. Instead, they had to radio for assistance. 

In September 2018, the MPS committed to the purchase and issuing of one hundred tablet 
devices, to be used as pool devices for MSC officers. The allocation of tablets across the MPS 
has been designated according to budgetary and operational demands. The roll out of these 
devices was completed in November 2018 and they have now been evenly distributed within 
frontline policing across the footprint of the MPS. Data usage is currently being collated, with 
the intention of increasing the pool size in the future.  It is to be highlighted that the use of a 
tablet  in  an  operational  situation  may  benefit  officers,  however  this  is  a  relatively  recent 
addition and officers are expected to use their police radios where tablets are not available. 
We have addressed this issue with the officers directly. 

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 2. 

In addition, the jury heard as follows. 

  The three police officers did not appear to have an in depth understanding of the misper 

process. 
On  their  initial  foundation  course,  all  MSC  officers  receive  training  on  how  to  deal  with  a 
missing person and are expected to be conversant with changes in legislation and policy.  The 
MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, 
or  indeed  any  police  officer,  is  unsure  of  how  to  deal  with  an  incident  they  should  seek 
supervisory  advice  at  the  scene.  In  light  of  this  incident,  all  MSC  coordinators  who  are 
experienced police constables supporting the MSC, have been tasked to review the support 
of MSC practical learning. 

The failures identified within this matter of concern represent individual failings which have 
been addressed directly with the officers concerned. 

  They did not (save for one who had attended such calls before) appear to have an in depth 

understanding of the s136 Mental Health Act / mental health potential issues. 

S136 Mental Health Act would not have assisted the MSC officers in this particular situation 
because it does not apply to a person inside a private dwelling.  

In  general  terms  the  MPS  response  to  incidents  involving  people  with  mental  illness  has 
evolved significantly over the  last few years and continues  to do so. We are committed to 
continual  training  and  partnership  working  which  has  been  incorporated  into  the  annual 
officer safety training programme for all officers, including MSC. MSC officers are provided 
with  mental  health  training  in  their  foundation  course  which  includes  awareness  of  signs, 
symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, 
which includes training, awareness and support for all officers. MSC are also incorporated into 
the  Home  Office  funded  MIND  Blue  Light  Champion  Programme,  whereby  selected  MSC 
officers, alongside regular officers, are trained as mental health champions. The role of these 
champions is to raise  awareness of mental health across the wider organisation, both  in a 
personal and professional capacity.  

  They did not consider using language line to assist them in obtaining information from the 
non native English speaking friend, with whom they spoke outside the building where Ms 
Cordero-Sanz was staying with a friend. Being able to speak in his native language might 
have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz 
was by now hearing voices. 

Language Line can be accessed via police Airwave radios at any time and full instructions on 
how to access this service is readily available on the MPS intranet. Instructions on how to use 
this and its benefits have been recirculated to the MSC via the duty sheet messaging system. 
The failures identified within this matter of concern represent individual failings which have 
been addressed directly with the officers concerned. 

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   Having been told that she would be upset by their uniforms, they did not insist on seeing           
Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes 
colleague, or suggest that they speak to the friend who was sitting inside with her. 

It has been established that the MSC officers who attended the address were not provided 
with the full details of the call.  The informants whom they spoke to did not indicate that Ms 
Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained 
more  information  at  the  scene  utilising  Language  Line  they  may  have  altered  their  risk 
assessment and seen her in person. Whilst the suggested considerations have merit, we would 
not seek to make them mandatory actions as they may not be appropriate or practicable in 
all  circumstances.  Had  the  MSC  officers  known  Ms  Cordero-Sanz  was  a  high  risk  missing 
person, MPS policy would have required them to physically see her and ensure she was safe 
and of no danger to herself or others. 

The failure to physically see Ms Cordero-Sanz is a collective failing by the MSC officers and has 
been addressed as previously detailed. 

  Nobody  thought  of  calling  an  ambulance  that  night,  save  for  the  CAD  (computer  aided 
despatch) operator who took the call in the first place, but he did not mention he had done 
so to anyone else. 

The  MSC  officers  did  not  consider  that  an  ambulance  was  necessary  based  on  the  limited 
amount of information they had when dealing with the incident. The initial CAD operator (call 
receipt)  requested  an  ambulance  attend,  based  on  the  information  given  to  him  by  the 
informant over the telephone and by asking relevant questions. The MSC officers did not have 
access to the CAD and were unaware an ambulance had been requested. They were told at 
the scene that she was safe and well inside the premises with friends and her family were en 
route. 

 

I wonder whether this suggests  a training need,  and/or whether, given the difficulties in 
maintaining skills on only 15 hours a month, consideration could be given to teaming special 
officers with regulars? 

The MPS has supported the dissemination of the learning opportunities presented by your 
report and is reviewing training in the context of both the MSC and the regular service. The 
MPS identifies that an aspiration to patrol MSC officers with regular officers on a regular basis 
would be unachievable due to competing demands, as well as MSC availability. As a direct 
result  of  this  incident,  CE  BCU  has  put  processes  in  place  to  ensure  that  MSC  officers  are 
briefed and debriefed at the start and end of their tours of duty and have supervisory support 
throughout. Commander Musker, the lead for frontline policing, has directed that this process 
be implemented across all other BCUs. 

3.  The  three  special  police  officers  who  attended  late  that  Friday  evening  /  early  Saturday 
morning were described as kind, and clearly demonstrated concern, but ultimately they did 
not know that they were dealing with a high risk missing person. Without tablets or a mobile 
data terminal, they had no means of checking this themselves. 

The jury found that the special sergeant and the CAD operator did not actively listen to one 
another.  This  meant  that  the  Merlin  system  was  not  checked  again  after  officers  had 

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 obtained Ms Cordero-Sanz’s full name, missing the opportunity to match her details with 
those reported earlier and to identify her as a high risk misper. 

The issue relating to availability of tablets and mobile data terminals has been addressed in 
matter of concern 1.  

The failures identified within this matter of concern represent individual failings, which have 
been  addressed  directly  with  the  officers/staff  concerned.  The  opportunity  was  missed  to 
provide the CAD operator with Ms Cordero-Sanz’s full name as the MSC officers at the scene 
assumed the CAD operator already had this information. In relation to checking the Merlin 
system,  this  will  be  dealt  with  under  matter  of  concern  4.  The  expectation  is  that  officers 
update the CAD fully once details have been obtained at the scene. The MPS accepts that if 
the MSC officers had access to a tablet on the night, then they could have carried out their 
own PNC check on the full name they had written down, which in turn would have informed 
them Ms Cordero-Sanz was a high risk missing person, however a PNC check should still have 
been carried out on their MPS Airwave radio. 

4.  There was not a full understanding among the CAD operators of how to search with only 
part  of  a  name  e.g.  CORDERO*  as  a  wild  card.  This  seems  a  significant  omission  in  the 
understanding of those fulfilling that role. 

Two issues arise from this matter of concern, which are detailed below: 

  Merlin has limited capacity to perform ‘wild card’ searches. It has no Boolean capability 
and cannot perform searches of terms within a certain distance of other terms; it is the 
system, and not the operators, that is limited in this way. More importantly, no wild card 
searches could have assisted in this case, since the CAD operator (call receipt) only had 
the  first  name  to  search  on  and  therefore  had  no  reason  to  contemplate  a  wild  card 
search.  The  spelling  was  provided  phonetically  and  the  CAD  operator  could  not  have 
known that it was wrongly spelled. In any event, it would not have been reasonable to 
search for ‘Rosareo’ multiple times with every letter in turn replaced with an *. 

  The second CAD operator’s (call despatch) mistake was not related to wild card searches 
either. His error was not to check Ms Cordero-Sanz’s name and its phonetic spelling with 
the officers at the scene. However it is acknowledged that CAD operators have numerous 
demands placed on them at any one time and are generally dealing with multiple calls. 
This was a failure of communication and active listening, and has been dealt with by way 
of local learning for the MSC officers and the second CAD operator. 

Conclusion 

The MPS believe there was not one defining moment but rather a series of errors or omissions that 
were contributing factors towards not identifying Ms Cordero-Sanz as a high risk missing person. 

As detailed within this response,  the responsibilities and actions expected of officers in relation to 
many  of  the  matters  of  concern  raised  are  all  covered  by  a  framework  of  guidelines,  policy  or 
legislation.  They  are  also  provided  in  foundation  training  and  refresher  training.  The  errors  and 
omissions identified within your report mostly represent individual failings or lack of understanding. 

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 All officers have a duty to maintain their professional knowledge under the College of Policing’s Code 
of Ethics (Duties and Responsibilities); training and reference materials are readily available to support 
officers and staff. 

Following  the  inquest,  these  matters  were  dealt  with  under  a  gold  group  governance  structure, 
chaired by Commander Musker, to address and implement a plan of action both at CE BCU and across 
all other BCUs regarding the identified issues. The critical need to have effective ongoing supervision 
for MSC officers was recognised and implemented as part of the action plan. This process is influenced 
by learning from day to day operations and vulnerabilities highlighted from investigations including 
inquests. 

Yours sincerely, 

Richard Martin 
Deputy Assistant Commissioner 

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