Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0076, written 24 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 | 24 Mar 2020 |
|---|---|
| Reference | 2020-0076 |
| Deceased | Kelly Sutton |
| Coroner | Geoffrey Sullivan |
| Coroner area | Hertfordshire |
| Category | Suicide (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
oe Signed by Geoffrey Sullivan Title Senior Coroner Jurisdiction Hertfordshire ] REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Constable of Hertfordshire Constabulary, Charlie Hall CORONER | am Geoffrey Sullivan Senior Coroner for Hertfordshire 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. http://Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/pa made INVESTIGATION and INQUEST On 06/09/2017 | commenced an Investigation into the death of Kelly Marle SUTTON. The Investigation concluded at the end of the inquest taking place on 17" & 18th March 2020. The cause of death provided by the pathologist: 1a) Features consistent with hanging After Inquest: The medical cause of death: 1a) Hanging The conclusion: Suicide contributed to by domestic abuse. For the five months preceding her death Ms Sutton was in an abusive relationship. Following her death on the 26" August 2017, a police investigation and trial at St Alban’s Crown Court resulted in the conviction of Ms Sutton’s partner for controlling or ccercive behaviour In an Intimate relationship and two counts of assault. He recelved a custodlal sentence of 4 years 3 months Imprisonment and a criminal behaviour order was imposed. In addition to the part played by her reiationship, the Inquest examined two Issues that related to Hertfordshire Constabulary. The second also relates to the Police Service more widely. The first issue concerned the attendance of police officers at Ms Sutton’s home on the ot July 2017, responding to a disturbance reported by a neighbour and the adequacy of their actions at the time. The second issue, which was highlighted in the Domestic Homicide Review (DHR), related to the availability of non-crime information to the police. In this case, there was no match with records in respect of domestic abuse by Ms Sutton’s partner against other victims, despite there being reports to the pollce from 3 previous partners. These reports, being non-crime reports, were not available to officers unless they searched for the victims, as opposed to the perpetrator. This sort of information is clearly of value to Inform officers’ decision making, when dealing with a report of potential domestic abuse and clearly of value when seeking to safeguard more widely the vulnerable partles In abusive relationships. | heard evidence that Hertfordshire Constabulary recently launched a new case management system ‘Athena’ which links POLE data (People, Object, Location and Event) which will assist with identifying where perpetrators have more than one victim and reveal a history of such behaviour. Hertfordshire Is part of a nine-force consortium with Bedfordshire, Essex, Cambridgeshire, Norfolk, Suffolk, Kent, Warwickshire and the West Midlands. The forces have access to the data of the consortium members. | also heard that there are other similar systems and consortia in other parts of the country. I did not find that either of the issues outlined above regarding Hertfordshire Constabulary caused or contributed to the death of Kelly Sutton. The Athena system Is a welcome development for safeguarding the vulnerable but based on the evidence | heard, | am concerned that this sort of information sharing is limited to forces within certain groups and is not a national resource. CIRCUMSTANCES OF THE DEATH The circumstances of the death recorded at the inquest: On 23 August 2017 at 08:15hrs Kelly Sutton's partner called 999 requesting an ambulance. He had found Ms Sutton hanging from a door handle in the living room of her home address. Pollce and paramedics attended and following CPR a return of spontaneous circulation was achleved by paramedics. Kelly Sutton was conveyed to the Lister Hospital where despite treatment her death was confirmed on the 26 August 2017. In the 5 month period leading up to her death, Kelly Sutton was subjected to coercive, controlling and abusive behaviour by her partner, which contributed to her death. 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. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) That non-crime information valuable to the police in safeguarding potential victims of domestic abuse is not available as a national resource. It is still limited to individual police areas or groups of areas. (2) (3) ~) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Charlie Hall, Chief Constable of Hertfordshire, have the power to take such action (in your capacity as Chlef Constable, Lead and Chief Officer of Athena and your presence on the National Police Chiefs’ Council}. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19" May 2020. |, the coroner, may extend the period. Your response must contain detalls 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 Solicitor representing members of the family and, The Welwyn Hatfleld Community Safety Partnership, who may find it useful or of interest. lam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish elther or both in a complete or redacted or summary form. He may send a copy of this report to any person who he belleves 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. | 24/03/2020 Signature Geoffrey Sullivan Senior Coroner Hertfor
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.
. Direct Line: .illllllll@herts.pnn. police. uk Date: 10 June 2020 Dear Mr Sullivan, I write in response to your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Miss Kellie ·Sutton. This was passed to me as the lead for safeguarding in the force and I apologise for the delay in returning a response. To address the 'Matters of Concern' : (1) That non-crime information valuable to the police in safeguarding potential victims of domestic abuse is not available as a national resource. It is still limited to individual police areas or groups of areas. At the time of Kellie Sutton's death in August 2017, all non-crime data in Hertfordshire was held on a force specific standalone IT system called the Crime Investigation System (CIS). The Police National Computer (PNC) was, and still is, the nationally used database which records a person's criminal record including impending prosecutions and arrests which result in no further action. It does not contain general intelligence information, non-crime data, or details of calls to police etc. In Hertfordshire all officers are trained to access PNC. The Police National Database (PND) went live in 2011 to enable enhanced provision of information on a national basis. The PND has 3 strategic aims, namely; • Protect Children and Vulnerable Adults • Prevent Terrorism o Prevent 8: Detect Crime, particularly Serious and Organised Crime. Since 2011 the functionality of PND has been enhanced, with a desire to ensure better decision making to protect the public. The PND system is owned by Home Office Digital Data and Technology (HODDaT), it is recognised by the Home Office as 'National Critical Infrastructure'. The PND provides more investigative opportunities than PNC but access is restricted to licenced users and Hertfordshire has 180 of the 12000 nationally available licences. Whilst PNC will return an instantaneous result, PND requires a written application to be submitted to a licence holder. Immediate/threat to life requests Police Headquarters, Stanborough Road, Welwyn Garden City, Hertfordshire, ALB 6XF 'Reducing Crim atching Criminals, Keeping People Safe' Hf.RT := ORDSHIRE I can take up 2 hours for a response to be received, however routine requests can take up to 7 days, therefore PND is assessed as a secondary investigative tool and would not generally be used at the scene of ~n incident. Since 2017 national governance around the utilisation of PNC has improved significantly but it is recognised that potential gaps still exist, especially in relation to frontline access. In May 2018, Hertfordshire joined with eight ot her forces to share a common integrat ed crime and i ntelligence platform called Athena which replaced a myriad of independent legacy systems. Athena allows each force to access .the other's intelligence, custody, crime and non-crime records, vastly improving our ability to safeguard the vulnerable and det ect crime. Similar to PNC every officer has immediate access to Athena. The move to Athena was a significant and positive step and addresses some of your concern. However, it is accepted that although significant progress has been made there is still scope for more non-crime information to be available across force boundaries. On a national level the Home Office through the National Law Enforcement Data Programme (NLEDP) has created the Law Enforcement Data Service (LEDS). LEDS will provide police and other law enforcement agencies with current and joined-up information - on demand and at the point of need - to help prevent crime and better safeguard the public. This work will, in due course, result in the decommissioning of the PNC and PND. The LEDS platform will hold the multiple existing data sets currently in the PNC and the PND for law enforcement to be accessed via a single interface. I am sure you will appreciate that the development of such a system is extremely complex and will take time to develop and implement but t he potential is worth the investment. The Codes of Practice for LEDS was published on 10th June 2020 for a 3 month consultation process and can be found here: https://www.colleqe.police.uk/What-we-do/Standards/Codes of practice/Paqes/Law- Enforcement-Data-Service.aspx. Hertfordshire Constabulary is fully committed to working towards the best opportunities for sharing data held by the police, and as part of our response to the consultation we will use the circumstances of Kellie Sutton's death and your observations to help i nfluence the way NLEDS progresses. Yours sincerely Assistant Chief Constable Police Headquarters, Stanborough Road, Welwyn Garden City, Hertfordshire, AL8 6XF 'Reducing Crim atching Criminals, Keeping People Safe' Hf R !F: 08DSHIRE
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