Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0051, written 3 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2020 |
|---|---|
| Reference | 2020-0051 |
| Deceased | Katrina O’Hara |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr K Malthouse, Minister of State for Crime, Policing and the Fire Service; 2. National Police Chiefs’ Council; 3. College of Policing 1 | CORONER I am Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset. 2 | CORONER’S LEGAL POWERS I 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 8 January 2016, an investigation was commenced into the death of Katrina Margaret Mary O'Hara, born on 14 April 1971. The investigation concluded at the end of the Inquest on the 19° February 2020. The Medical Cause of Death was: Ia Stab Wounds to the Chest The conclusion of the Inquest was as follows: “The conclusion of the jury as to the death of Katrina O’Hara is that she was unlawfully killed. During his interviews with both police and mental health professional the ex partner cooperated fully, answering all questions and presenting as a plausible and reasonable individual giving no indication that he was likely to cause harm to Miss O’Hara. He was controlling and manipulative and Miss O’Hara’s actions were influenced by his attempts to control her. The ex partner used threats both to Miss O’Hara and her family to try to maintain his control and even his threats to commit suicide and his suicide attempt were more to exert influence on Miss O’Hara rather than real attempts to end his own life.” CIRCUMSTANCES OF THE DEATH On the evening of 7" January 2016, Miss O’Hara was at her place of work, a barbershop in | Miss O'Hara was outside of the shop when she was approached by (EEE also known as i who was Miss O'Hara’s ex-partner. [EEEEEEUsed a kitchen knife to stab Miss O'Hara, who was sadly pronounced deceased at the scene. was apprehended nearby, having cut his own wrist. He survived his self-inflicted injury and is now serving a life sentence, having been convicted of Miss O’Hara’s murder. At the time of the offence, [was on conditional police bail for offences of stalking, assault and threats to kill, with a condition that he was not to have contact either directly or indirectly with Miss O'Hara, having been arrested on 30" December 2016 for those offences and having been released pending further police investigations. CORONER’ NCERN 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. During the inquest evidence was heard that: i. On 29" December 2015, Miss O’Hara telephoned 999 to report that |_| was stalking and harassing her and that he had assaulted her and threatened to kill her. It was established by the call handler that Miss O’Hara’s call was not an emergency, so she was advised to call back on 101, the non-emergency line. Miss O’Hara did not telephone again, though her adult son, a telephoned the police, without her knowledge, on 30" December 2015 to report what he had been told about (MJ behaviour. Although Dorset Police have now changed their policy, so that if Miss O’Hara’s call was received today the 999 call handler would have taken the details, that change has arisen out of investigations conducted into the circumstances surrounding Miss O’'Hara’s death. A senior Dorset Police Officer who gave evidence regarding the changes made in Dorset was not able to provide an assurance that similar policies are being adopted by police forces nationwide. ii, Miss O’Hara’s son, [J contacted the police on 30" December 2015 to report his concerns about the risk JJ posed _to_his mother. MI <0 oor: concern about the risk posed to himself: had told others he was on the ninth page of his suicide note. In addition, in the preceding 6 weeks the police had been called at least four times to attend upon at: regards to concerns for his welfare; he had made repeated threats to family and N others that he would take his own life. A senior police officer with considerable domestic abuse experience that reviewed the incident log of 30" December 2015 created following [EEE call, recognised that the suicide risk EM posed to himself increased the risk that I posed to Miss O’Hara. However, the recognition of suicide risk of a perpetrator as a particular and significant high risk factor for a victim, was not explicitly recognised in the Dorset Police Domestic Abuse Investigation Policy and Procedure until more recently. A senior Dorset Police Officer who gave evidence regarding the changes made in Dorset was not able to provide an assurance that similar policies are being adopted by police forces nationwide. After Miss O’Hara’s adult son, i contacted the police on 30% December 2015, police made contact with Miss O’Hara. She confirmed the account provided by her son and attended a local police station to provide a statement to the police. When Miss O'Hara provided a statement to the police in support of the complaint made on 30% December 2015, Miss O’Hara’s mobile telephone was quite properly seized in order that it could be forensically analysed by police to retrieve evidence that would substantiate the allegations that she made. However, Miss O’Hara was not supplied with a replacement phone. When approached by Mon 7" January 2016, she had no means of contacting the emergency services. Dorset Police now have a large stock of “pay as you go” mobile phones to supply to the victims of crime who have had their phones seized for evidential purposes. This has arisen in Dorset from learning arising out of investigations into the circumstances surrounding Miss O’Hara’s death. I have not been assured that such phones are available to victims in similar circumstances across all police forces in England and Wales. Following the complaint that was made on 30 December 2015, | a as arrested and interviewed under caution the same day. HE was not charged with any offences as further enquiries were required before approaching the Crown Prosecution Service for a charging decision. Therefore, he was released on conditional bail to return to the police station. The condition attached to PY bail was that he was not to have any contact in any manner whatsoever either directly or indirectly with Katrina O’Hara. On 4" January 2020, I was reported to the police for breaching his bail conditions: he had instructed his daughter to send a text message to Miss O’Hara’s daughter, asking “will your mum drop the charges or not” (referring to the complaint of 30 December 2015), thereby having indirect contact. A statement was then taken from Miss O’Hara’s daughter by uniformed police officers. However, due to a lack of familiarity with what was, at the time, a new police software product that assists the police in managing information and tasks, “Niche”, the information relating to the breach of bail was not communicated to the officer in the case for the substantive matter. Therefore, no action was taken against Jj in relation to the breach of bail conditions and no further investigation, beyond the taking of the statement, was conducted by police. Essentially, the “task” to obtain a statement to evidence the breach of bail conditions was not linked on Niche to the original “occurrence”, relating to the substantive occurrence. The net result was that no notification was sent to the officer in the case, when there was an expectation by all police involved on 4" January that such a message would be sent and that the officer in the case could review the breach of bail conditions and decide upon appropriate action. I heard evidence that all officers in Dorset Police have or will be receiving further training in relation to the functionality of Niche and that Dorset Police are exploring the possibility of an officer in a particular case receiving an automated notification through Niche if there is an addition to the occurrence log for that case. . Ihave concerns with regard to the following: I am concerned that Police Forces across England and Wales may still be employing a policy similar to that previously employed by Dorset Police, with regard to non-emergency calls made to 999. Dorset Police have recognised the courage it takes a victim of domestic violence to make a call to the police so have now ensured that, depending on the risk level and whether police attendance will be required, the call will either be taken by the 999 call hander, or, where it is deemed that no police attendance at any time is likely required, the caller will be called back at a later convenient time. It is no longer left to the victim to make a subsequent call to the police in relation to the same complaint. The concern is that if similar policies are not in place across the police forces in England and Wales, victims of offences, who may have had to take a huge risk to themselves or others to make the call to the police, are being asked to call back on a different number if their call is not categorised as an emergency. Dorset Police have changed their Domestic Abuse Investigation Policy and Procedure to include the suicide risk of the perpetrator of domestic abuse as a significant risk factor to the victim of domestic abuse. This is a recent change and reflects the growing understanding that the perpetrator who has “nothing left to lose” poses a significant risk to his or her victim. I am concerned that this change in policy in Dorset may not be reflected nationwide. It is not unusual that the mobile phones of victims are seized by police as part of investigation into domestic abuse related allegations. Until the death of Miss O’Hara, Dorset Police did not provide replacement phones, leaving victims potentially without a means to communicate with others, including in an emergency. As stated above, Dorset Police now have a store of mobile phones available to supply to victims where their phone has been seized as evidence. I am concerned that this may not be in place across the police forces of England and Wales and that victims in some areas are being left without the means of contacting others, including the emergency services, when their phones have been seized by police during an investigation. “Niche” is a software program used by, I understand, 23 police forces across England and Wales. I do not know if more forces are due to adopt Niche in the future. I am concerned that appropriate training needs to be provided to police officers to ensure they have a good understanding of Niche and how to “link” events to an occurrence and to ensure that the appropriate individuals, for example the officer leading an investigation, are notified of any developments in a case. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation 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, 28" April 2020. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) EE representing the family of Miss O'Hara; (2) The Chief Constable for Dorset Police; (3) representin (4) EERE Solicitors, representing Dorset Healthcare NHS Foundation trust; (5) Independent Office for Police Conduct. 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated Brendan J Allen 3™ March 2020
2 responses 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.
Home Office ' Brendan J Allen Assistant Commissioner for Dorset By e-mail: Coro ner.Service@bcpcouncil.gov.uk Kit Malthouse MP Minister of State for Crime and Policing 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 30 June 2020 Dear Brendan, Regulation 28 Report to Prevent Future Deaths - Katrina Margaret Mary O'Hara Thank you for your letter of 3 March regarding this Regulation 28 Report. am sorry for the delay in replying, due to the original letter going astray. I was very sorry to read about the circumstances of Ms O'Hara's death. Tackling domestic violence is a priority for this Government. While many positive steps have already been taken to protect victims, we know that more remains to be done and, in parallel with other work, our landmark Domestic Abuse Bill which is currently before Parliament will further strengthen protections for victims while helping to tackle perpetrators. The matters you raise in relation to call handling, seizure of evidence and police training on Niche systems are primarily operational matters for the police. However, the Home Office liaises closely with policing leads and the College of Policing on domestic abuse issues and understands that domestic abuse cases are accorded a high priority by forces . Experience during the recent pandemic lockdown period has seen police forces employing innovative tactics to ensure that victims of domestic abuse can contact them in a wider range of ways - including for example on line as well as by telephone - as well as targeting high risk perpetrators. Police forces will be maintaining and building on such innovation as lockdown eases and good practice will be shared through the College of Policing. In respect of potential risk indicators in perpetrators, the Home Office is working with a number of police forces and the College of Policing to pilot and evaluate approaches to identifying and tackling high risk offenders. This work includes adding suicide indicators to the list of potential risk indicators. In parallel work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides. We expect the results to be used to review or refine the current risk assessment processes as well as helping to identify useful interventions with perpetrators or potential victims. We are fully committed to doing everything that we can to protect victims of domestic abuse and violent crime and to reducing future homicides. Kit Malthouse MP Minister of State for Crime and Policing
Mr Brendan Allen
Assistant Coroner
Coroner for Area of Dorset
9 June 2020
Re: Katrina Margaret Mary O'Hara - Reg 28 Coroners' {Investigations) Regulations 2013.
Dear Assistant Coroner
Thank you for sight of your report to prevent future deaths regarding the murder of Ms
O'Hara. This has been brought to my attention as the National lead for Contact
management within the National Police Chief's Council
The matter of concern raised that is relevant to Contact Management is, as I understand it:
that Miss O'Hara originally contacted police via 999 and, when a call handler determined
that the call was not an emergency, was advised to ring back on 101.
Since 2015 there has been a major refresh of the National Contact Management
Strategy. This has been undertaken under the auspices of the National Contact
Management Steering Group and was approved by Chief Constable's Council in January
2019. Following on from the approval of the strategy a corresponding, comprehensive,
review of the Principals and Practice for Contact Management has also been undertaken .
Our revised principles and practice cover this issue.
The Principles also make clear that, as a national service, there should be limited deviation
in this - this is a position endorsed by the Home Office. I would not intend to clarify or
amend further in light of the Coroners comments.
Also, and again as outlined in the P&P, all Contact Management staff should use the
National Decision Making Model and a risk based decision making model - the most
common of which is THRIVE or THRIVE+. This provides a structured and accessible decision
on initial grading.
I will raise your report at the next meeting of the National Contact Management Steering
Group for the awareness of all forces.
1st Floor, 10 Victoria Street, London SWlH 0NN I 020 3276 3796 I www.npcc.police.uk
However, it should also be borne in mind that 999 is a national system with specific criteria,
and it would appear that it was a case of inappropriate channel selection as outlined within
those National criteria.
I trust this is of assistance
Yours sincerely
Assistant Chief Constable
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