Chelsie Greatorex

Home Secretary 

     2 Marsham Street 
     London SW1P 4DF 
     www.gov.uk/home-office 

Graeme Irvine 
Area Coroner 
Eastern Area of Greater London 
Walthamstow Coroners Court,  
Queens Road 
London 
E17 8QP 

DECS Reference: 

Dear Mr Irvine, 

Thank you for your letter of 11 November 2020 enclosing a copy of the Regulation 
28 Report to Prevent Future Deaths, written following the Inquest touching upon the 
death of Ms. Chelsie Violet Greatorex.  

In your letter you ask that I ensure the matters you have raised are considered by 
the Metropolitan Police Service. I should stress that the Metropolitan Police Service 
is operationally independent and, as such, will respond separately on the specifics of 
the investigation in question. I am therefore responding to the Coroner’s concerns 
only in so far as they relate to national policy. 

I was deeply saddened to learn about the death of Ms. Greatorex and I would first 
like to express my deepest condolences to her family for their unimaginable loss.  

Rape and sexual assault are devastating crimes. The government expects every 
report to be treated seriously from the point of disclosure, every victim to be treated 
with dignity and every investigation and prosecution to be conducted thoroughly and 
professionally. We want victims to have the confidence to report these crimes, 
knowing they will get the support they need and that everything will be done to bring 
offenders to justice.  

That is why, along with the Ministry of Justice and the Attorney General’s Office, the 
Home Office is currently carrying out a review of the criminal justice response to 
rape. The scope of the review covers the length of the criminal justice process, from 
police report and investigation through to final outcome in court, so that we can take 
a comprehensive view of any issues that need to be addressed within the system 
and take action accordingly.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The review is considering several issues which related to the matters of concern you 
have reported. These include the provision of support for victims during the criminal 
justice process; the role of specialist officers with training in rape and sexual assault 
investigations; and causes of delay to investigations. The review will report in due 
course with a package of actions for cross-system improvement. I am determined 
that measures we take following the review will ensure more effective handling of 
cases and the timely delivery of justice and support for victims of these awful crimes. 

Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, 
you may also wish to be aware that the government will shortly be publishing a first 
of its kind national strategy on tackling all forms of child sexual abuse. A key element 
of this strategy will be working across government to improve the way the criminal 
justice system responds to child sexual abuse and to ensure victims and survivors 
receive the support they deserve. We will continue to prioritise child sexual abuse as 
a national threat in the Strategic Policing Requirement, to empower police forces to 
maximise their specialist skills and expertise to tackle these crimes.  

The Regulation 28 Report raises specific concerns about the level of communication 
and information that Ms. Greatorex received from the police during the investigation 
and the support that was offered to her. The government wants to ensure that the 
rights of victims are recognised at every stage of the criminal justice system. For this 
reason, we recently published a new, restructured Victims’ Code which sets out 12 
key overarching rights regarding the support that victims should receive from the 
police, courts and other criminal justice agencies. We will also be consulting on a 
new Victims’ Law that will guarantee that victims receive their rights under the Code 
and agencies are held to account for delivering them. 

Furthermore, the government is committed to ensuring access to high quality support 
for victims and survivors of rape and sexual assault, wherever they live in the country 
and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has 
awarded £12m to 91 rape support centres across England and Wales to provide 
independent, specialist support to victims of sexual violence, including victims of 
child sexual abuse, an increase of £4m from 2019/20. The government has also 
announced that an additional £4m per year until 2022 will be invested in recruiting 
more Independent Sexual Violence Advisers (ISVAs) who play a vital role in 
informing and supporting victims at every stage of the criminal justice process.  

Thank you for writing to me on this important matter. I hope that my response has 
demonstrated the government’s commitment to improving the criminal justice system 
response to rape and sexual assault and to ensuring that victims and survivors 
receive the support that they need. 

Rt Hon Priti Patel MP 
Home Secretary

_| METROPOLITAN
POLICE

PROFESSIONALISM HQ

Deputy Assistant Commissioner

Mr Graeme Irvine New Scotland Yard
Area Coroner for East London, Victoria Embankment
Walthamstow Coroner’s Court, London

Queens Road, SW1A 2JL
Walthamstow,

E17 8QP ;
Email:
Tel lor 101
Your ref:
Our ref:

Date: 30 December 2020

TeXece Ma Iecscnes

| am the Deputy Assistant Commissioner (DAC) for Professionalism in the Metropolitan Police
Service (MPS) and | am responding on behalf of the Commissioner of Police of the Metropolis in
response to your Regulation 28 Report to Prevent Future Deaths dated 12'° November 2020. Your
report was sent following the conclusion of the Inquest into the death of Ms Chelsie Greatorex.

On 19" June 2020, the Directorate of Professional Standards Specialist Investigation Unit (DPS SIU)
conducted an investigation into police contact with Ms Greatorex prior to her death on 10" March
2020. A report was compiled using various sources of evidence, including, but not limited to, the
statements of the investigating officer, crime reports, Computer Aided Despatch (CAD) messages
and Missing Persons & Related Linked Indices (Merlin) reports. This report will be referred to in this
letter when addressing the areas you have raised.

The response to the matters of concern is as follows:

Evidence heard in the inquest suggested Ms Greatorex felt anxiety regarding her role as a
complainant in a sexual assault trial

The DPS SIU Investigation Report details a number of occasions when Ms Greatorex reached out to
the investigating officer about feeling anxious and low. They appear to have formed a trusting
relationship and when Ms Greatorex appeared to become particularly low, the investigating officer
offered Ms Greatorex advice and a referral to a support agency. However, Ms Greatorex reassured
the investigating officer that she was fine. On the day Ms Greatorex was informed of the date of the
trial, there was little to suggest to the officer that she was feeling very low or in need of any further
support other than what would be normally ponsideray during a difficult time for any complainant in a
case such as this.

To further support Ms Greatorex, on the approach to the trial an application was made to the court for
“special measures” of which | know you will be familiar. This process would have included a pre-trial
visit to the court, a private room and further support at the court.

In order to provide additional support for victims and/or witnesses throughout the entire investigative
process, the MPS has introduced a THRIVE+ vuinerability assessment which is currently being
trialled and is anticipated to be rolled out across the MPS in April 2021. It is a set of principles and a
framework to assess the type of policing response or investigation required for a particular set of
circumstances. THRIVE covers: Threat —- Harm — Risk — Investigation — Vulnerability - Engagement +
Prevention/Intervention. The framework is a tool which aligns to and enhances the National Decision
Model and includes the assessment and ongoing review of risk during investigations. It also provides
a common language around risk to improve information sharing and decision-making.

Despite the fact that Ms Greatorex was a child when the events of the allegation took place the
investigation was not conducted by a specialist officer or team

Delays in the investigation were identified:

e Despite naming the suspect and their place of study, no interview took place for over 3
months

e A decision to prosecute was not arrived at until late December 2019

e Acourt hearing was not listed until January 2020

The allegation Ms Greatorex made was considered at the outset by specialist officers and it was
decided that due to the non-complex nature of the investigation, it would remain with a Response
Team officer to investigate. The MPS General Investigation Policy states that “Where there is a
requirement for ownership of crime investigations by the initial investigating officer, there may be
occasions where the characteristics of specific investigations identify themselves as serious and/or
complex. It is important that this is identified as soon as possible so that the most appropriate
investigating unit is assigned to that investigation dependent on that seriousness and/or complexity. If
serious and/or complex characteristics are present, then CID should be approached to take on that
investigation”. The policy provides details of types of crime that are considered complex and, ‘If the
crime type is not listed above and there are no serious or complex characteristics, then the
responsibility for further investigation must stay with the response team officer’. In this instance, the
crime was retained by the Response Team Officer to investigate.

The MPS recognises that as the investigation was not considered complex, it should have been
completed in a quicker timeframe. The MPS have therefore made improvements in the supervision
and team structures of response teams to support less experienced officers with their investigations.
A Response Support Team was set up on North East Basic Command Unit on 23% September 2020
and blends together resources from Emergency Response Policing Teams, Local Resolution Teams,
Criminal Investigation Departments and probationary officers and their mentors. The Response
Support Team functions as a training unit and allows for a steady improvement of officers
investigative skills and point of contact for advice.

The observations about the length of the investigation and failure of management systems to
adequately prioritise Ms Greatorex’s case are being addressed with the introduction of a new
product, the vulnerability tool, which has been developed for Basic Command Units’ monthly
Offender Management Meetings which prioritise outstanding named suspect cases when the victim”
has been identified as being the subject of some form of vulnerability. This allows for management
intervention and looks across all offence types to identify cases where progress should be prioritised
for the benefit of victims where an element of vulnerability has been identified. The vulnerability tool
highlights those cases where the suspect has not been arrested and/or interviewed after two months
and involves a vulnerable victim; for example, a person who is mentally unwell, who has a physical
impairment, is under the age of 18 years; this is not an exhaustive list. Therefore, by using the
vulnerability tool, it is intended that similar cases to this will be identified as requiring management
intervention and prioritisation.

The timeliness from when the decision to prosecute and the court hearing lies with the CPS and Her
Majesty’s Courts Service (HMCS). The suspect for this allegation was interviewed on 5"" November
2019 leading to a submission of the evidential file to the Crown Prosecution Service (CPS) on 26"
November 2019. The investigating officer made further contact with the CPS on 18" December 2019
regarding the decision on a charging authority and seeking to expedite the case. The CPS authority
was granted on 27"" December 2019. The suspect was served charges on 2™ January 2020 with a
first court appearance provided for the end of the month.

When Ms Greatorex sought support from the MPS, no contact was made for four days, even
then, the extent of the support was an email with the contact details of a borough
psychologist support service

The investigating officer stated throughout the investigation that her contact with Ms Greatorex was
either in person or by telephone as Ms Greatorex’s expressed preferred method of contact. Ms
Greatorex would email the investigating officer asking her to call her, but was aware that due to her
shift pattern the officer may not be able to call her back for a few days.

The investigating officer was of the understanding that Ms Greatorex was also receiving support from
her college through weekly meetings with a guidance counsellor. When Ms Greatorex made the
officer aware that she was feeling anxious as she was getting into trouble at college for leaving doors
open, the officer agreed to speak with the staff about this which she did.

The DPS SIU Investigation Report outlines the occasion when Ms Greatorex had emailed the officer
on 4 March 2020 as she had felt a little low and wanted someone to speak to.. The investigating
officer had previously told Ms Greatorex that she could contact her at any time by email and that she
would respond as soon as she was able. The officer returned the call on 7'" March but reached her
voicemail. On 9" March the investigating officer checked her emails from home and saw that a court
date had been arranged for January 2021. The officer then telephoned Ms Greatorex to inform her.
The e-mail of 4° March 2020 was discussed and Ms Greatorex explained that at the time of writing
the email she had just had one of those days but everything was fine now. The officer asked her
what she meant by feeling low and Ms Greatorex said that she had been worried about the case and
what it would entail. The officer asked if she had someone she could speak to if she felt low and Ms
Greatorex said she had an aunt she saw and spoke to regularly. The officer explained to Ms
Greatorex that she was always welcome to talk to her but that she may not be the best person to
help her with her mental health so she would email her details for Newham Talking Therapies (NTT).
The officer also offered to refer Ms Greatorex other agencies, which she declined. Ms Greatorex said
she was happy speaking to her aunt and would contact NTT if required. The conversation ended with
Ms Greatorex in good spirits, talking about a recent exam and saying that she would be in contact
soon. The investigating officer provided Ms Greatorex with the NTT details despite what was said in
the conversation. During this conversation, the officer said in her statement that it did not appear to
her that Ms Greatorex was in a mental health crisis and her responses led the investigating officer to
think that the low feeling had passed and, although worried about the case, there was a network of
support in place.

The MPS is committed to progress learning from instances of death by suicide involving victims and
suspects and further develop the response to these. A small team of dedicated officers leading this
work has focused on the delivery of key areas. The team is developing a Suicide Prevention Policy
Document and Toolkit. The publication of this policy is a key step in developing our co-ordinated
strategy to suicide prevention. The policy will draw together information on suicide prevention,
support services, risk indicators, contacts and best practice. It will be accompanied by a toolkit
providing easy to access guidance and advice from signposting support services to identifying key
partners. A draft external Suicide Prevention Policy is due to be drafted by the end of December
2020 prior to going through the MPS’s internal policy development process.

In addition to the policy publication, the suicide prevention team is committed to improving the
training and guidance available to all officers and staff. An investigative standards’ document is under
development and is designed as an easy to follow key points to consider document for police first
responders. This will enhance knowledge and understanding across the entire service and build on
the additional guidance that is already used by some teams where death by suicide is considered
higher risk i.e. Custody, Online Child Sexual Abuse.

The MPS Suicide Prevention Team is also meeting with other police forces to learn and share good
practice.

In Conclusion

| would like to express my condolences to the family of Ms Greatorex. The MPS is committed to
supporting all victims of crime and assisting them to get justice where possible. | recognise that this
can't happen unless complainants and victims are adequately supported throughout what can pal
be a very challenging investigation and criminal justice process.

| hope this provides’ you with the reassurance that the MPS has considered cle addressed the areas
of concern that vol have raised.

Please do not hesitate to contact me should you have any queries.

Yours sincerely

Deputy Assistant Commissioner