Emily Greene

South Yorkshire 

pOLlCE 

Chief Constable   5 DEC

7th December 2020 

DJ Urpeth 
HM Senior Coroner 
Office of HM Coroner 
Medico-Legal Centre 
Watery Street 
Sheffield 
S3 7ES 

Dear Mr Urpeth, 

Your reference: Req 28 report to prevent future deaths followinq inquest into the 
death of Miss Emily Greene. 

Dear Mr Urpeth, 

I hope this letter finds you in good health. 
I  am  writing  to  you  today  to  provide  South  Yorkshire  Police's  response  to  the 
Regulation 28 report to prevent future deaths following the inquest into the tragic 
death of Miss Emily Greene. 

I enclose our response at Appendix A attached. This report addresses separately, 
each of the six matters of concern raised. South Yorkshire Police are committed to 
learning the lessons from this case and I would like to reassure you that we have 
already taken action in respect of the findings. 

I  also  enclose  with  this  letter,  the  Sexual  Offences  booklet  (CID40)  and  the 
document Complete Victim Care (CVC) that are referred to in the report for your 
attention and assistance. 

I would also like to invite you to visit one of our 10 Achieving Best Evidence rooms 
within  the  Force.  As  is  referred  to  in  the  report,  although  all  of  these  are  fit  for 
purpose, there is currently a programme of refurbishment taking place to enhance 
them. 

 
 
 
 RESTRICTED 

Police Headquarters 
Carbrook House 
5 Carbrook Hall Road 
Sheffield 
E-mail: chief@southyorks.pnn.police.uk 
S9 2EH 
Please do let me know if you require any further information, or alternatively, if you 
would prefer to seek out the opportunity to discuss these issues further in a face to 
face  meeting.  I  am  of  course  more  than  willing  to  take  on  board  any  particular 
advice or further feedback. 
Yours  Si  c  r  ly, 

Chief Constable 

 
 
 Matter of Concern 1: 

There was employment of an officer into a specialist sexual offences unit without the officer being 
given specialist training before he started work: 

 was the OIC (Officer in the case) in relation to the investigation in which Emily 

Greene reported historic sexual offences against   

joined South Yorkshire Police in January 2017 having been previously employed by the 

DC  
Metropolitan Police Service between 2007 and 2014. Having been on a career break for less than 3 
years he was accepted as a direct transfer, in accordance with our recruitment policies. 

When  Dc—was  accepted  by  South  Yorkshire  Police,  he  provided  information  that  he  had 
undertaken a variety of training courses and had attained the level of a PIP 2 accredited Detective. 
This qualification indicated that DC— as capable and suitable to investigate serious and complex 
investigations. 

On reviewing the training records of DC

 f0110wing can be confirmed: 

Date 

Course 

March 2007 

Joined Metropolitan Police 

July 2007 

April 2009 

July 2009 

Dec 2010 

April 2011 

May 2011 

April 2012 

June 2014 

June 2014 

June 2014 

June 2014 

Dec 2016 

Jan 2017 

Jan 2017 

Completion of foundation training 

Investigative Interview of Suspects — Serious and Complex 

Primary Investigative Training — Critical Incident Sexual 
Offences 

Serious and Complex Interview Course 

Crime Investigators Development Programme 

Crime Investigators Development Programme PIP 2 

PIP 2 Investigator Accreditation approved 

Public Protection — Abusive relationship 

Public Protection — Family disturbance 

Public Protection — Initial response 

Public Protection — Missing Daughter 
Email to SYP confirming DC PiP 2 status 

Joins SYP less than 3 yrs out so direct transfer 
Completed 7 day Transferee Course 

March 2017 

Human Trafficking And Modern Slavery Training 

May 2017 

May 2017 

Investigator Masterclass 

Specialist Child Abuse Course — SCAIDP 

Pass/ Fail 

Pass 

Pass 
Pass 
Pass 

Pass 

Pass 

Pass 
Pass 
Pass 

Pass 

Pass 

Pass 

Pass 

Pass 

Pass 
Pass 
Pass 

We have highlighted for your assistance the parts of the record relevant to his role and the 
investigation subject to your Inquest. Of note, the PIP2 completion in April 2012 indicates that DC 
was assessed as capable of undertaking serious and complex investigations, including sexual 
offences and the status of Detective awarded. 

On the commencement of service within South Yorkshire Police in January 2017, DC 

attended a 

7-day transferee induction course, covering systems and processes within the organisation. 

1 

 
 investigative background, he was posted to the Child Protection team at Barnsley, 

Due to 
commencing late January 2017. It appears that he worked on a regular basis with another very 
experienced Detective within the unit. As a consequence of this review the process for transferees 
has been revisited and there is now an expectation that on moving to their substantive post a local 
mentor in the same department will be formally appointed to ensure familiarisation with local 
processes and practice not covered at induction. 

In May 2017, and contrary to the evidence provided at the inquest by D 
Investigators masterclass followed by the nationally accredited Specialist Child Abuse Investigation 
Development Programme (SCAIDP). This is a national specialist course designed by the College of 
Policing and is aimed at developing investigators working within the Child Abuse Investigation arena 
from the both the Police and Social Care. 

he attended an 

The objectives of the course are to: 

  Develop  an  understanding  of  child  development  and  identify  vulnerabilities  of  child 
development in the context of abuse, including understanding the paediatrician perspective 
in terms of non-accidental injury. 

 Develop  an  understanding  of  sexual  offending  behaviour  including  grooming  and  apply  the 

knowledge to child abuse investigations. 

  Develop a sensitive, ethical and anti-discriminatory approach through policing principles in 
identifying, assessing and responding to complaints of child abuse and evaluate risk factors 
within the investigation. 

  Develop  an  understanding  of  the  multi-agency  working  approach;  the  practices,  policy, 
procedures  and  legislation  that  binds  the  working  relationship  together  in  Child  Abuse 
Investigations. The second week on SYP also includes refresher Achieving Best Evidence (ABE) 
victim training. 

Modules include: 

  Child development in context of abuse 

  Understanding sexual offending behaviour 

Investigating child abuse 

  Multi-agency working — in practice 

Safeguarding 

  Attachment & Development 

  Behaviour & Assessment 

  Trauma, Facts & Statistics 
  Offences 

South Yorkshire Police continue to deliver the national SCAIDP course in partnership with the four 
local authorities within South Yorkshire. One of the key objectives is to ensure cross over learning 
with the other agencies and for officers to better understand and be able to contribute to successful 
partnership working. 

2 

 
 
 
 
 
 In conclusion, the above details and his training record since 2007 demonstrate that DC—wasa 
trained and accredited detective from his time in the MPS. On arrival in South Yorkshire Police, he 
worked alongside an experienced public protection DC before passing the national SCAIDP course 
four months later. D 
offences involving child victims and was suitably qualified and experienced to undertake the 
investigation involving Miss Greene. 

has received extensive training in relation to the investigation of sexual 

South Yorkshire Police does however recognise the importance of doing its very best to equip 
public protection officers and we are therefore developing a bespoke course for staff to attend 
when they are first posted to work within the department. This course will give additional training 
around areas including Child Abuse, Sudden Unexpected Death of a Child or Infant, Child Sexual 
Exploitation, Neglect, Multi Agency working and victim care and referral services. The course will 
work in partnership with the nationally recognised SCAIDP course to ensure staff have a wide 
knowledge base of both local and national processes. This course is currently being developed by 
subject matter experts from across the force, it is anticipated this course will be delivered from 
April 2021 onwards. 

Matter of Concern 2: 

There were deficiencies by the investigating officer and SYP in relation to the investigation 
into the allegation of sexual assault. 

It  is  accepted  that  the  initial  investigation  into  the  allegations  made  by  Miss  Greene  were  not 
investigated  to  the  standard  expected  by  South  Yorkshire  Police.  After  the  tragic  death  of  Miss 
Greene,  the  allegations  were  reviewed  and  the  reviewing  officer  concluded,  this  investigation 
appears to fall well below the standards of what would be expected when serious sexual allegations 
are made by a 13yr o/d girl against a male suspect who was 18 at the time. 

The review also established that the decision to file the investigation was inaccurately recorded 
and lacked rationale, with the reviewing Detective Inspector not having a full oversight of the 
investigation and actions undertaken by DC 
reinvestigated and the case submitted to the Crown Prosecution Service. 

This review led to the allegations being 

South Yorkshire Police have processes in place to ensure that all investigations on allocation to an 
OIC have a clear investigation plan, this includes guidance to the OIC around evidential actions, lines 
of enquiry and safeguarding. Vulnerability is also assessed with guidance around support services 
that are available to the victims and other parties involved. The investigation plans are completed 
by Sergeants and are recorded electronically on the investigation. 

There is further supervisory oversight every 28 days; again this is conducted by the first line 
supervisor who is a Sergeant. There is further review of the investigations every 4 months by an 
Inspector. 

As a minimum, the Force expects the  following to be  considered and recorded during the review 
process: 

1.  Victim safeguarding and contact - both actual and future — e.g. what have you done / what 
referrals have been made? What does the victim contact regime look like? Is it sufficient for 
the crime type and is it being followed? 

3 

 2.  Suspect Risk — both now and future - e.g have you assessed the ongoing risk posed by the 

suspect, what is your decision making around arrest / circulation and why? 

3.  Investigative priorities - is there an investigative plan — have the actions been addressed? If 

not why not? How will you remedy this? 

4.  Should we investigate - is there a crime? Should we investigate? If not why not? If not, can 

the crime be filed? 

5.  Due diligence — is the investigation being conducted with due diligence. If not, who or what 

are the blockages? How long will it be for these issues to be resolved or finalised? 

6.  Future reviews and supervisory governance — who is to check on whether this investigation 
is  being  progressed?  Will  there  need  to  be  an  interim  Inspectors  review  to  ensure 
momentum? 

7.  Support Agencies — Does the victim require referral to a partner agency such as Social Care, 

ISVA or IDVA services or counselling. 

An assessment of the quality and efficacy of the investigation review process has recently taken 
place. All crime mangers have been reminded of the process and have been requested to cascade 
this process to all supervisors. Compliance with the investigation review process in terms of both 
timeliness and quality is subject of regular scrutiny and performance reporting. 

The CID 40 Sexual Offences booklet used by officers attending the initial report of sexual offences 
has  been  reviewed  and  updated.  This  booklet  acts  as  an  aide  memoire  for  officers  and  includes 
information around victim care, officers' actions and suspect management. The revised booklet is 
currently being distributed across the Force, and the necessary amendments are also being made to 
the Force intranet site. A copy of the new booklet has been attached for your reference. 

The investigation undertaken by D as referred to the Independent Office for Police Conduct and their 
assessment remains ongoing at this time. 

Matter of Concern 3: 

There was lack of clarity around the BSARC referral and its actioning. 

The SARC (Sexual Assault Referral Centres) support service covers all four areas of the Force. 
Barnsley is covered by the BSARC service. The referral process for victims of sexual offences is in 
place for officers and staff to make a request for support via the professional's portal central on the 
BSARC webpage. These referrals are sent and allocated at the central hub for ISVA/ CHISVA service, 
located in Doncaster. It has been identified that the referral officer does not receive any 
acknowledgment that the submission was successful. It has also been identified that different 
officers used alternative referral processes such as direct emails to ISVA managers and phone calls. 

The direct and single point of referral has been reinforced to all officers via the Force intranet page 
signposting  them  to  the  current  process  and  to  ensure  they  have  a  full  understanding  of  that 
process. 

4 

 The current process for officers, as highlighted below, is found on the dedicated PVP page on the 
Force intranet or the individual SARC service internet pages. 

Independent Sexual Violence Advocacy 
The ISVA (CHISVA for Children) service helps anyone who has been the victim of unwanted sexual 
contact offering practical  support to  deal with circumstances. Their aim is  to help give people the 
confidence, support and information they need to take control of the situation and move forward. 
The CH/ISVA  will establish the  needs of the person  and put support plans in  place. Working with 
other support agencies such as: 

o  Health services & Emotional wellbeing; 
  Liaising with schools & 
education; o Housing & Benefits; 0 
Therapy. 

The CH/ISVA will work with the Police and the rest of the criminal justice system. Examples of the 
type of support we will provide include: 

Liaising with the police, courts, Crown Prosecution Service (CPS) and other public agencies; 

o 
o  Keeping the client informed of developments in the case; 

  Advocating on their behalf; 
  Supporting before and during any court case. 

How to refer to the CH/ISVA Service: 

Complete the form on this link: https:/(isva-referral.drasacs.org.uk/ 

Under  the  Victims  Code,  the  'explicit  consent'  of  the  person  being  referred  is  required.  If  the 
referral is for a child, the consent of the parent/guardian must be obtained. 

The services are delivered locally in Sheffield (SRASAC), Rotherham (RothACS), Barnsley (BSARCS) 
and  Doncaster  (DRASACS)  by  the  four  providers  that  are  part  of  the  South  Yorkshire  Sexual 
Violence Partnership, with all referrals being managed at the central Hub in Doncaster. 

The force and the commissioned ISVA services are working together to improve the referral process, 
ensuring that referrals are acknowledged by the ISVA service along with the development of a form 
in which the officer will complete with the consent of the victim and then forwarded to the ISVA 
service. Officers will be directed to electronically record the submission within the investigation along 
with follow up enquiries with the ISVA service to ensure the victim is being supported. 

This document will be incorporated into the revised Investigation booklet that has been developed 
for attending officers, to support them whilst dealing with rape and sexual offence investigations. 

Work is ongoing with the SARC service to provide officers with a confirmation of a referral request 
being received. When this is in place, officers will be instructed to add this to the investigation 
record. 

Matter of Concern 4: 

That Emily was never personally seen to sensitively explain the fact of and reasons why the 
police were not going to take the allegation any further. 

5 

 
 
 
 It is accepted that Emily should have been seen face to face to explain the decision not to take the 
matter any further. In 2017, the Force had in place a clear Victim Codes of Practice (VCOP) policy on 
which all officers are fully sighted, the policy is supported by booklets to be distributed to victims of 
crime, it is accepted that booklets with bespoke information may not have been readily available at 
that time to provide to Miss Greene and her family. 
Since  this  time  the  framework  of  Complete  Victim  Care  (CVC)  has  been  developed  resulting  in 
significant improvements in how the Force provide victim care. The force has a dedicated theme 
lead along with a regularly updated intranet page and a victim care booklet. The current booklet 
entitled 'Supporting Victims' contains information for victims and allows the officer to record their 
contact details and the next steps of an investigation. 

Within the booklet, there are details of support agencies available including support for victims of 
both sexual abuse and domestic violence. The Victims Right to Review (VRR) process is explained 
within the booklet detailing that the process came into effect on 1 April 2015 and applies to all 
recorded crime offences. 

The  VRR  section  further  details  under  what  circumstances  a  review  can  take  place  and  how  the 
process is undertaken. The section quotes, the intention of the scheme is to give you a way to appeal 
a decision not to prosecute. The right of a victim to request a review happens where the police: 

e Make a decision not to bring proceedings in cases where the police are able to charge or 
  Make a decision that the case does not meet the relevant threshold for referral to the CPS 
for a charging decision. 

You are allowed to request a review within three months of being notified of the case being filed, as 
this is the period during which they can request a judicial review. 

Within the force intranet page, there is the force document under VCOP on a page where the officer 
is given guidance of the process and the expectations of the force in relation to victim care. Some of 
the key areas from the page are below. 

Update the victim within five working days or within ono day enhanced victlm, if a 

suspect is: 

Update victim 

First contact with victim 

Complete astez;rnent to  

enhanced vitt:ms 

and complete  
done contact or no tctcc than five days after •.hc first 

Victims bc.okk•t (this 

• 
• 

to download the Oc•oklet Via our 

501.tthyork5.pollco.uÅ 

• victim that their detail' will be pasted on to Victim Support 
Services (VSS), the victim ESP-tan d that th%' can attn the at any 
time 
• Victims don•t havo to updates from any within the VCOP. they 
cut. emplain and record. They can opt in at M'/ time by con:actng 
the CIC VS$ 
• It is the  
to be pussed to VSS 
• Record crime within hours. 

choice. not yours, whether they wloh for their detuils 

• 

• 

• 

• 

H+legsed Without charge 

Char," to o,'  

ot 

• 

If  

the  

Other updatea to be provided Ot regular intervals following discussion with the victim 
Neco,'d that the victim has teen 

• 
Outline Pollcc Victim Right to  

and CPS Victims Rloht to Review Scheme. 

CPS not to 

6 

 
 
 Enhanced victims 

Victims of most seftus crimes aæ; a close relative bereaved by a criminal 

offence.  a  victim  of  domestic  væce,  hate  crime,  terrorism,  sexual 

offences,  human 

trafficking,  attempt  murd% 

kidnap, 

false 

imprisonment, arson with intent, wounding or causing GBH with intent 

(sec18 offences only) 

'   targeted victims are those who have been targeted repeatedly asa 

direct victim of crime over a period of time, padiculaiy if they have 

been deliberately targeted are victim of a sustained campaign of 

harassment or stalking 

• Vulnerable and Intimidated victims those defined by 

Section 16 and 17 Youth Justice and Criminal Evidence Act 1999. 

Victim Support 
• Police team sends referrals of all recorded 
crime incidents (excluding domestic violence) 
to Vctim 
Support by automatgc date transfer on a dad}' basic 
• VS ease management system performs vulnerability 
based automatic triage. All vtct'ms cf sexual offences 
ate forwæ•ded to the South Yorkshire Independent 
Sexual Violence Partnership for initial contact, triar and 

support 
• Victims eat't!ed to enhanced zenices {in line 
with VCOP/ dtrectea to VS Cope & Recovery' 
team and a'lccat±d a Vtctvrn Care ACvocete 
(VOA). to make phone contact within 24hrs. 
complete a needs and risk assessment.  
end otte support 
• Support required; VCA acts az a single point of contzct 
throughout cnrnjnal justice process. coord/nating 
v;ctirn cate w•ith multi-agencies. Provide advocacy 
services, information about CJS and emotional support 

to "Sist victims, cope and tecover the Impact of come 
• Vict.ms not entittea to enhanced service sent 
auto text with VS contact detai)s, web 
telephone access 
• Victims  

agents can  
Support at any point in time 

the 

to 

The force's management of victim care is 
monitored on a regular 
basis through victim care satisfaction surveys along with being reviewed and discussed at quarterly 
District performance days. The learning from this case has been discussed with District 
Commanders to ensure qualitative review takes place. 

following a   Incident. 

Ms Greene and her family would have been entitled to the enhanced victim service and it 

is accepted that DC— did not provide this to the family. It is also accepted that DC 
provide the family with the any information in relation to the appeal process. 

It is accepted that DC—should have seen the family face to face, and in particular Miss Greene, to 
explain the rationale as to why the matter was not progressing to the Crown Prosecution Service. It 
should  then  have  been  explained  that  they  could  appeal  this  decision  with  the  District  Crime 
Manager who holds the rank of Detective Chief Inspector. 

The force will ensure  all  officers  are  fully  sighted  in  the appeal  process  and  ensure  that the CVC 
booklet is provided to all victims of crime. 

Matter of Concern 5: 

There was (and I understand still is) lack of a suitable room for taking the victim video at 
Wombwell police station (due to a parent not being able to be accommodated) 

The Achieving Best Evidence Guidance (ABE) issued by the Crown Prosecution Service (CPS) 
provides guidance to officers in relation to having other persons present in the interview room. This 
guidance states that Interview supporters can be present in the interview room if it is deemed 
necessary and would provide emotional support to the victim. This would only be if appropriate and 
practical: 

Parent(s)/carer(s) should not be automatically excluded from this role, but their appropriateness will 
very much depend on the circumstances and nature of the case, together with any issues arising from 
the allegations made by the child. 

There are also good reasons why their presence may not be in the best interests of the child. 
Research suggests that the presence of a carer or parent at the time of the interview can actually be an 
additional source of stress if the child is concerned about them hearing unpleasant details. 

7 

 
 
 In  addition,  the  child  might  feel  uncomfortable  about  someone  they  see  on  a  daily  basis,  knowing 
intimate details of their personal life. Other witnesses in the case, including those giving evidence of 
an early complaint, cannot act as interview supporters. 

Further guidance can be found in the below national CPS document. 

https://www.cps.gov.uk(sites/default/files/documents/legal guidance/best evidence in criminal 
proceedings.pdf 

Miss Greene did make a first disclosure to her mother resulting in her mother being a witness, and 
on this basis, it would have undermined the evidence and gone against the national ABE guidance 
to have allowed her in the room. 

The ABE interview of Emily took place at Wombwell Police station, which was fit for purpose. The 
ABE room contains seating for the victim, officers and any third party such as an interpreter or 
intermediary if it was identified the victim required one. There is a waiting room very close to the 
ABE room where parents or other people who are there to support can wait. An officer would 
explain to the parent and the child that should they become distressed, the interview could be 
paused and the officer would offer to ask the parent / carer to offer support to the victim. 

South Yorkshire Police has 10 Achieving Best Evidence rooms within the Force, all of these are fit for 
purpose but there is currently a programme of refurbishment taking place to enhance them. Four 
sites have been refurbished in the current financial year and there is a plan to refurbish all 
remaining ABE rooms, including Wombwell, over the next financial year. There have been delays in 
this work due to the COVID 19 restrictions. 

Matter of Concern 6: 

There was mishandling of the missing person report. 

South  Yorkshire  Police  would  refer  to  the  evidence  of
summary; 

 which  provides  the  following 

On the 13th November 2018, 3 days before Miss Greene was reported missing, the Force introduced 
a brand new incident management platform, called 'Smart Contact'. A full review of the reporting of 
this incident was undertaken and it established that the operator within the communications room 
was grading the call on the standards and processes relating to the previous management system. 

The initial calls by the family were received by West Yorkshire Police and redirected to South 

Yorkshire  Police.  The  incident  created  at  19.39hrs  was  graded  as  'Resolve  Without  Deployment' 
(RWD). This grading would mean that the incident would be dealt with solely over the phone. It was 
identified at 20.56 as being graded incorrectly and it was regraded as a priority. The priority grading 
means a response time of 60 minutes should be met. 

It was established within the review that the incident remained unallocated for a further 71 minutes 

at which time resources were allocated, however there were further delays before officers arrived. 

In total, it was 3hrs and 3 minutes from the initial call to officers arriving at the home address of Miss 
Greene.  This  time  is  not  what  is  expected  of  either  the  Communications  room  staff  or  attending 
officers for this type of incident. 

8 

 The new incident management system is now fully embedded within the Communications Centre 
and all staff are fully trained, understand and are familiar with the grading process. Staff receive 
ongoing developmental training. The force is due to implement a new 'missing from home' IT 
system  called 'Compact' which will improve the forces management and recording of persons 
reported missing. This new system commences in April 2021. 

9