Anne-Marie Nield

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lan Hopkins QPM PO L | Cc [Ee
Chief Constable >»

FAO HM Senior Coroner Ms Joanne Kearsley
Mrs Lisa Hashmi

HM Area Coroner, HM Coroner’s Court

The Phoenix Centre

L/Cpl Stephen Shaw MC Way

Heywood
O19 1LR 21 March 2019

Dear Mrs Hashmi

Re: Regulation 28 Report following the Inquest touching upon the death of Anne-Marie
Nield

Thank you for your report sent by email dated 31 January 2019 in respect of Anne-Marie
Nield (deceased) and pursuant to Regulations 28 and 29 of The Coroners (Investigations)
Regulations 2013 and paragraph 7, Schedule 5 of the Coroners and Justice Act 2009.

Having carefully considered your report, GMP accepts in full the points raised. As a
consequence, your report has already led to detailed discussions within GMP’s Professional
Standards Branch as to the issues which have arisen in this and other cases, with a view to
taking further co-ordinated action to address the concerns identified. | have provided more
detail of these measures below and reply to the specific issues raised as follows:

1. During the course of the evidence, it became apparent that almost all of the Police
Officers involved in this case did not understand or apply the Domestic Abuse
Policy properly. In particular, they did not understand the meaning of important
terminology such as ‘repeat victim’, ‘repeat perpetrator’ and ‘serious and serial
perpetrator’. An understanding of and the ability to apply this policy are critical to
the risk assessment process and the prevention of domestic homicide.

The existence of the Domestic Abuse Policy and the content of it are discussed in the
student officer training_in the initial stages of training and during consolidation training. As
was acknowledged Cy I cing the inquest, GMP’s Domestic Abuse Policy does
require updating and will include non-fatal strangulation as a heightened risk factor for
victims of domestic abuse. The policy will also need to include significant structural changes
within GMP in relation to public protection and a new operating system called iOPS. The
structural, procedural and IT changes need to be embedded before the new policy can be
written to ensure it is meaningful and fit for purpose by enabling police officers and staff to
effectively respond to, and reduce incidents of, reports of domestic abuse.

The concepts of ‘repeat victims’, ‘repeat perpetrators’ and ‘serial and serious perpetrators’
are examined in a group exercise format using the “Murdered by my boyfriend” DVD with
tasks attached which are fully de-briefed by the trainer. This exercise has also been rolled
out on the Safeguarding for Constables training events aimed at frontline officers who are
substantive Constables working in Response / Neighbourhood policing teams.

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2. Markers are not being placed on police systems (e.g. OPUS) in line with policy and
Procedure. Markers are all the more important where resources are finite and
demands placed upon the Police Service are increasing. Markers help in
identifying / conveying risk and vulnerability.

It was acknowledged that in this case, the perpetrator of the domestic abuse on Anne-Marie
Nield was not flagged on GMP OPUS (GMP police operating system) or PNC (Police
National Computer) systems to indicate that he was a serial and serious perpetrator of
domestic violence. Similarly, although it was clear from Anne-Marie’s own police records
that she was a repeat victim of domestic abuse, this was not clearly flagged by way of a
marker,

There is not currently a force policy or guidance document on warning markers. The
decision whether to add a warning marker (WM) to an individual’s nominal profile (OPUS
profile) depends solely on the professional judgement of officers.

Any police officer or support staff member having contact with an individual directly (at an
incident or in custody for example) or indirectly (such as receiving a report or processing
information / intelligence about them) can update their profile with a WM (a marker that is
nationally recognised and applicable to both GMP systems and the PNC).

of the Force Intelligence Bureau (FIB) is tasked with
writing GMP’s first force policy and guidance document on the use of WMs. This will be
completed when several key factors can be fully considered. This includes seeing the
capability of our new iOPS system and awaiting mandatory reform requirements from the
Anthony Grainger Public Inquiry (which is likely to include necessary actions required around
WMs). Part of this policy will be that officers and staff are actively encouraged to place
appropriate WMs on police records to help manage risk.

As a force, we are currently in the process of implementing a_new, integrated operating
system which will replace many of our existing systems. el 3: worked closely
alongside the iOPS team to ensure that all requirements for safely managing intelligence are
met.

GMP have provided the following as essential functions in relation to markers:

1) The ability to add, update, review and remove WMs.

2) Automatic notifications to officers to complete mandatory reviews of WMs.

3) Mandatory recording of the provenance of a WM and a link back to more detailed
information / rational.

4) Mandatory recording of the officer updating and the time / date.

iOPS senior leadership team reassure me these requirements will all be in place in the new
system in time for go-live (no set date has been confirmed yet).

5) There will be a detailed warning message to be displayed within the system. This warns

officers accessing information that they must not act on a WM without reviewing the
information that sits behind it:

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“Warning! This system and the data within are restricted to authorised users for appropriate
policing purposes. Unauthorised access could constitute an offence under the Computer
Misuse Act and be considered as a breach in data protection. Users are reminded to ensure
that any intelligence or personal information obtained from this system is still relevant before
acting upon it. Users are asked to pay particular attention to Flags and Warning Markers and
we encourage users to review the information behind the marker wherever possible.”

This warning message has been implemented and can be seen in the test system.

3. There is no reference to ‘non-fatal strangulation’ within the current Domestic
Abuse Policy. Furthermore, almost all of the Police Officers in this case failed to
appreciate the significance of non-fatal strangulation as a specific factor for
domestic homicide.

At the time of Anne Marie’s death non-fatal strangulation was not terminology widely known
by officers and no training had been given on it, as relatively little was then known about the
incidence of non-fatal strangulation in DA victim ined greater recognition as a
consequence of some work between GMP ——e looking at non-fatal
strangulation in other contexts but soon recognising that there was a potentially significant
link to domestic abuse. As a consequence, the one-day safeguarding course, which has

been delivered since May 2018 to frontline officers, now includes reference to non-fatal
strangulation as a specific risk factor for domestic homicide.

Non-fatal strangulation awareness training now also forms part of the Safeguarding for
Constables course, aimed at the frontline responding officers, and of the Consolidation
training course for student officers, whereupon it is explained in the context of being a High
Risk indicator at the point of completing a DASH risk assessment. It is also covered on the
Specialist Adult Abuse Investigators Course, which is aimed at district detectives. In all of
these sessions it is explained that, where there is a history of non-fatal strangulation, the risk
factor should be raised owing to the prevalence of it in domestic homicide cases.

4. There was little, if any, contact made with the deceased after her partner was
charged and granted conditional bail by the Court following the allegation made on
the 11th March 2016. Policy and Code were not followed.

GMP accepts that further efforts should have been made to engage with Anne-Marie and to
make and maintain direct contact with her, notwithstanding that contact was made with her
former partner at her request. Since Anne-Marie’s death, many of the safeguarding
procedures for victims of domestic abuse have been enhanced. VCOP and the Victims’
Strategy are embedded in training across all of the IPLDP programme and in particular
during the Victim / Witness interview sessions. This also includes signposting to partner
agencies and charitable organisations and promoting best practice by issuing “End the Fear”
leaflets and other literature.

The CPS has mandated that a domestic abuse history is provided with every DA case
including the overnight remand applications, as soon as they get to Court. The CPS
immediately shares this information with Probation, which in turn can feed into assessments
or risk for bail. This was not in place at the time of this homicide and would have increased
the potential for safeguarding as a broader range of professionals would have had sight of
the information and been able to make their own assessment. The Court can, and does,
take into account any police-held history and the CPS have remanded suspects based on
that alone in Manchester.

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Upon review, this case was not heard in a specialist Magistrates’ Court. It arrived in a
Saturday Court and was then heard in standard lists, which regrettably offered no further
opportunities to identify the potential risks involved. Now, all DA cases in Greater
Manchester are heard in a specialist court, which tends to result in a greater understanding
of the possible risks and appropriate safeguarding measures to take in relation to bail
conditions and remand options.

5. Risk assessment and the exercising of professional judgement in relation to the
level of risk were inadequate and ongoing/dynamic risk assessment was not
carried out. A referral to MARAC was not made and the DVDS not offered to the
deceased, again outwith expectation.

As indicated the course of her evidence to the inquest, there were
grounds on whicteawmnaw Teferral could have been made in Anne-Marie’s case. It is
further accepted that use of, and disclosures pursuant to, the DVDS scheme have improved
significantly in the intervening period. As part of the IPLDP initial and consolidation training
and the Specialist Adult Abuse Investigators Course, training is provided on the DVDS
scheme, as well as on risk identification, assessment and management by means of
structured teaching on DASH. This includes the explanation of the RARA model and the
definitions of Standard, Medium and High Risk. At the conclusion of the IPLDP, student
officers also receive a further four hours training around risk identification and assessment
and are then qualified to finalise their own cases that they deem to be “Standard Risk”. The
Specialist Adult Abuse Investigators Course provides an input from an IDVA who delivers
training around the MARAC process to district detectives.

However, aS was also acknowledged in the inquest, the MARAC process can be quite
intensive and requires the active participation of the individual. Regrettably, it can be no
more than speculation as to whether Anne-Marie would have felt able to co-operate with
these additional services, had they been offered to her.

6. Whilst the Court recognises that findings of the Domestic Homicide Review and
Independent Management Review were accepted in their entirety by the Force and
that some action has been taken since in order to address the shortcomings
identified, | am concerned to note that two and a half years since the death of Ms
Nield not all the recommendations of the DHR and IMR have yet been implemented.
This is potentially putting victims of domestic violence at risk.

The Serious Crime Division Coordination (SCD) Unit are responsible for coordinating all
recommendations received by GMP as part of any post-incident review or investigation and
plan, record and monitor all action which is taken in response to those recommendations.

Over 90% of frontline officers have now received vulnerability / safeguarding training, with a
number of further inputs planned in 2019 for those who did not receive it during their initial
training. Training in safeguarding in the context of Domestic Abuse is constantly being
reviewed and GMP is currently looking to update the material. DA training is currently
undergoing a Quality Assurance process.

Proposed further action by GMP

It is acknowledged that despite the aforementioned measures having been introduced that
the training and learning has not been thoroughly embedded across GMP. To ensure that
the recommendations of past reviews are considered and implemented in full, GMP’s
Organisational Learning Board will compile recent similar incidents, look for common themes
and report back to the Force’s strategic lead for domestic violence.

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In order to refresh and reinforce the training, undertake field test sampling of whether it is
embedded in practice and provide an improved service to victims of domestic abuse, the
following three broad actions will be taken forward:

1. For this investigation to be used as a case study for a video briefing to be played at
briefings to frontline officers and staff, emphasising the below learning points, and
any additional points raised in the Organisational Learning Board, and why they are
important:

Non-Fatal Strangulation

VCOP

Definitions

Markers / Flags

Risk rising due to an escalation in incidents

The closing of standard risk cases and referrals.

2. Increase and improve GM's IDVA service, including the ambition for IDVA services to
offer support to medium risk victims when they are involved in a Court case. The
rationale being that when a DA victim is supporting (or involved) in a live case it is an
obvious and clear additional risk factor as it represents a threat to the perpetrators
control of the situation.

3. ‘Field Test’ frontline officers and practitioners knowledge through dip sampling cases
and random, informal, questioning of practitioners.

| hope that this response is helpful in outlining the actions that we are taking to address the
issues that you raised and in demonstrating our total commitment to learning lessons from
tragic events such as those which led to the death of Ms Nield, so that we can do our utmost
to prevent such incidents from occurring in future.

Yours sincerely

lan Hopkins
Chief Constable

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