Prevention of Future Deaths reports · 2019

Lesley Armstrong

Regulation 28 report to prevent future deaths, reference 2019-0136, written 4 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Apr 2019
Reference2019-0136
DeceasedLesley Armstrong
CoronerTony Brown
Coroner areaNorth Northumberland
CategoryPolice related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

Tony Brown LLM when Sy 17 Church Street
H M Senior Coroner 5 Berwick-upon-Tweed
North Northumberland 4

=a a TD15 1EE
ORE?
ET MON.
Tel : 01289 304318
Fax: 01289 303591

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Chief Constable Winton Keenen
Northumbria Police

Middle Engine Lane

Wallsend

Tyne and Wear

NE28 9NT

CORONER

| am Tony Brown, Senior Coroner, for the Coroner Area of North Northumberland

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.

INVESTIGATION and INQUEST

On the 19th November 2018 | concluded an Inquest into the death of Lesley Ann
Armstrong, who died at her home address on the 20th July 2016. | recorded my
conclusion that Mrs Armstrong had taken her own life, and that the medical cause of her
death was due to 1a) hanging.

4 | CIRCUMSTANCES OF THE DEATH

While working as a care assistant at the Riverside House Care Home, Morpeth operated
by Akari Care Limited, Mrs Armstrong had been interviewed by her employers regarding
injuries sustained by a resident at the Home, and was subsequently being investigated
by Northumbria Police for a possible assault under Section 47 of the Offences Against
the Person Act 1861. If that allegation was not proved, Mrs Armstrong and or her
colleagues might then have been investigated for an offence of neglect or lack of care,
under Provisions of the Care Act 2014, as a separate investigation by the Local
Safeguarding Adults Board.

On 21st April 2016 Mrs Armstrong was suspended from work as a result of the
allegations described above and was required to attend Bedlington Police Station on
30th April 2016 as a voluntary attender for interview under Police caution.

On 7th June 2016, a decision had been taken by Northumbria Police Officers
investigating the case to discontinue enquiries for the possible offence under Section 47

of the Offences Against the Person Act 1861. This was finalised as being - no crime |
detected due to evidential difficulties. Mrs Armstrong was not informed of this decision
as she should have been, and consequently believed herself still to be under suspicion
for a crime of assault.

On 20th July 2016 Lesley Armstrong’s husband John left their home to go shopping, and
when he returned home around 13.45 hours, he found his wife Lesley with no apparent
signs of life, as a result of hanging. A note from Lesley Armstrong was found,
expressing an intention of taking her life, and in the same note, swearing that she was
innocent of the accusations against her.

During the attendance by Police Officers following Mrs Armstrong’s death at her home
on 20th July 2016, it was recognised by one of the Officers that the investigation into the
suspected assault had been discontinued several weeks earlier, and that this was not
known to Mrs Armstrong.

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. —

It is recognised that employers have a duty of care to their employees to investigate
allegations against them promptly and keep them reasonably informed about the
progress of investigation of misconduct. On this occasion the employers Akari Care
Limited could not properly inform Mrs Armstrong about the status of their investigation
because they were not formally told when the Section 47 investigation by Northumbria
Police had been discontinued. Northumbria Police acknowledged at the Inquest that
there were procedural errors by two of their Officers, that the procedures themselves
required improvement and that they had taken steps to address these. It was not clear
that any practical steps had been taken to improve communication with the Local
Safeguarding Adults Board or the owners of the Care Home both of whom needed to
know when the Police investigations were completed so that the Safeguarding Board
could if necessary progress an investigation under the Care Act 2014, and the Care
Home could keep Mrs Armstrong informed about progress and her employment position.
That lack of information or progress caused Mrs Armstrong to believe she was still under
suspicion for an offence of assault .

It is not a matter for the Senior Coroner to attribute blame or to specify how procedures
between Northumbria Police and Northumberland Adult Safeguarding Committee should
be modified or improved, which is a matter for them to consider and organise. The
Senior Coroner does not approach the question as an expert, and his role is to draw to
the relevant parties’ attention the concern which has arisen from the circumstances
disclosed by the evidence at the Inquest, leaving them to address that concern by taking
steps to avoid circumstances which could lead to further deaths in the future.

ACTION SHOULD BE TAKEN

| believe that action should be taken to address the concerns raised by the
circumstances of Lesley Ann Armstrong’s death.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 30th May 2019. |, 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:-

Southerns Solicitors, Clyde & Co. Solicitors, Northumbria Police Legal Services, 7
| IOPC, a Senior Manager, Specialist Services,
Northumberland County Council. | 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.

DATE 04 April 2019

TONY BROWN
HM Senior Coroner for North Northumberland

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 Northumbria Police (PDF)
: POL ic BRIA
www.northumbria.police.uk C/A +) VERA BAIRD a
www.northumbria-pcc.gov.uk at lac ”)

POLICE & CRIME COMMISSIONER
Lg PO I. ICE

Legal Services

Newcastle City Centre Police Station
Forth Banks

Newcastle upon Tyne

Our ref: RFH/EL/IQ3/16 NEI 3PH

Tel: 0191 4373949
Fax: 01914936004
legal@northumbria.pnn.police.uk

6 June 2019

RECEIVED
Q7 JUN 2019

Mr Tony Brown LLM

HM Senior Coroner

17 Church Street
BERWICK UPON TWEED
TD15 1EE

Dear Mr Brown,

| write in response to your Regulation 28 Report dated 4" April 2019 (‘the Report’),
following the inquest touching upon the death of Lesley Armstrong.

In the Report you state that:-
(1) in your opinion there is a risk that future deaths will occur unless action is taken;

(2) Akari Care (Mrs Armstrong’s employer) could not properly inform Mrs Armstrong
of the status of their investigation because they were not formally told when the
police investigation had been discontinued and;

(3) it is not clear that any practical steps have been taken to improve communication
with the Local Safeguarding Adults Board (LSAB) or Akari Care, who needed to
know when the police investigation were complete.

| understand, therefore, you consider there is a risk of future deaths to employees
specifically in the care environment, who are under investigation by the police, where
employers and other supervisory agencies are not notified directly by the police as to
when the police investigation is concluded. | do not understand your opinion to
extend to employers generally, where their employees are the subject of a criminal
investigation.

Risk of Future Deaths

Unfortunately there is always a risk that an individual who is subject to a criminal
investigation may harm themselves. The risk of self-harm must necessarily be
determined on a case by case basis, having considered the circumstances of that
particular individual via a process of risk assessment. The inquest heard evidence

Mr. RF. Heron LLB Force Solicitor, Mr GS, Crute LLB Senior Solicitor
Miss. L, Silverton LLB Senior Solicitor, Mr: N. Wirz BA LLM Principal Solicitor, Mr K McKernan BA Assistant Force Lawyer (Solicitor)
Miss. H. Hebb LLB Assistant Force Lawyer (Solicitor), Mr: D.C. Foster Assistant Force Lawyer (Solicitor)

as to the risk assessment process. An assessment is undertaken both in respect of
suspects who have been arrested, and those who attend for interview voluntarily. In
addition, If, post risk assessment, further information is brought to the attention of a
police officer or member of police staff suggesting a risk of self-harm to the
individual, then that information will be considered and the risk assessment revisited.

In relation to Mrs Armstrong, no evidence was heard at the Inquest that Northumbria
Police officers or staff knew or ought to have known that Mrs Armstrong would take
her own life or otherwise injure herself. Whilst there was evidence that Mrs
Armstrong was experiencing mental health difficulties during the investigation, this
information was not passed to Northumbria Police.

Clearly a police investigation and any disciplinary investigation/process are stressful
for the subject but unfortunately | cannot agree with the suggestion in the Regulation
28 Report that Northumbria Police should have informed Akari Care that the
investigation was at an end. It is of course accepted that Mrs Armstrong should have
been informed promptly and this was not done due to individual errors.

Appropriateness of Information Sharing

In stating that Northumbria Police should not have informed Akari Care about the
status of the investigation it is important to highlight the purpose of information
sharing between the police, LSAB and the employer.

Sharing of criminal conviction data, or of information relating to allegations of criminal
conduct, is subject to the provisions of the General Data Protection Regulation
(GDPR) and the Data Protection Act 2018 (the Act). Such information is defined as
“special category data” (analogous to sensitive personal data under the earlier Data
Protection Act 1998). The legislation restricts the sharing of such information save in
clearly defined circumstances.

The purpose of information sharing between agencies, particularly in the care
context, is to safeguard care users. It is this purpose which potentially enables
disclosure of information relating to allegations of criminal conduct to be disclosed to
an employer. The purpose of such information sharing is not to enable the employer
to keep its employee updated as to the progress of the criminal investigation against
that employee. Disclosure for that reason would be unlawful, unless the employee
provided his or her consent and if the employee provided such consent, there would
of course be no need to notify the employer. If the employee requires an update as
to progress then it is clearly most appropriate that contact should be sought directly
with the police, or via the employee’s legal representative.

Northumbria Police is regularly contacted by employers seeking information
regarding criminal investigations relating to their employees. The Disclosure and
Barring Service Update Service provides a statutory system, in the care context, to
enable employers to obtain such information. Such disclosure requests are
necessarily considered on a case by case basis. Any automatic disclosure of

conviction information to employers, irrespective of the circumstances, would be
unlawful.

Requests by employers for disclosure of information require consideration of the full
circumstances. For example:-

e What is the nature of the alleged criminal conduct?

e How does it impact upon the employer's business and do they have a
legitimate reason for receiving the information?

e Is the alleged criminal conduct relevant to the employee’s work?

e What is the strength of the allegations facing the employee?

e What will the employer do with any information received?

e May the employer themselves be potentially subject to prosecution, and would
disclosure potentially prejudice such future proceedings?

Multi-Agency Meetings occur frequently and are attended by representatives from
the LSAB, police, social services, and other invited parties. The purpose and scope
of such meetings may relate to broad matters of policy, issues of general concern
across a region or area, or a specific case relating to a place (e.g. a school or care
home) or an individual. Employers would not usually be invited to attend such
meetings. Again, the purpose of such meetings is to safeguard clients, not to
safeguard the welfare of individuals subject to criminal investigation. Requiring.
agencies, in such multi-agency meetings, to also concentrate upon the welfare of
suspects, would detract from the statutory responsibilities imposed upon the
agencies involved and would lead to confusion. As you rightly state in your Report, it
is the employer which owes a duty of care to its employee.

For the above reasons, | consider that information regarding the conclusion of a
police investigation ought usually to be communicated directly to the suspect or their
legal representative by the investigating officer, and not through any third party. It is
the investigating officer who is usually best able to assess when and how such
information should be communicated to the suspect and, if appropriate, any other
interested parties. It is not appropriate that such updates should be given to
employers routinely. Decisions to disclose information to employers can necessarily
only be made on a case by case basis. Provision of information to employers as a
“fail safe” mechanism, on the assumption that they will update the employee, cannot
be appropriate and will be unlawful in the absence of the employee's consent.

As the evidence given at the Inquest made clear, there already exists a system
reminding investigating officers of the need to promptly inform suspects of the
outcome of a police investigation. Whilst the Inquest heard evidence that since Mrs
Armstrong death further training and guidance has been delivered (instigated by a
national review of voluntary attender processes led by the College of Policing), the
existing procedure was fit for purpose. The officers knew that Mrs Armstrong
required an update but, due to individual errors which were explained at the Inquest,
this unfortunately did not occur. As you are aware, the officers were dealt with
appropriately under Force conduct procedures for their errors.

Had Mrs Armstrong received notification that no further action was to be taken in
relation to the criminal investigation, then she still would have remained suspended

from work whilst the regulatory and internal investigations of the local authority and
her employer continued.

You can be assured that Northumbria Police take our responsibilities to
communicate with suspects very seriously. The evidence heard at the Inquest from
Superintendent Steven Heatley established that we adapt and improve our
procedures where appropriate. However, although careful thought has been given to
the matters raised in the Report, particularly given the tragic circumstances of Mrs
Armstrong’s death, for the reasons set out above it is not deemed necessary to take
further action over and above the actions already taken and of which you are aware.

Yours sincerely

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