Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0181, written 27 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 May 2021 |
|---|---|
| Reference | 2021-0181 |
| Deceased | Zeyna Partington |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Police related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) = REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable of Greater Manchester Police “GMP” 2. National Police Chiefs Council — Lead for ANPR CORONER lam Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 3 December 2020 | commenced an investigation into the death of Zeyna Partington the Inquest concluded on the 25" May 2021. CIRCUMSTANCES OF DEATH Mrs Partington was reported as a missing person to GMP on the 8" August 2019. She was believed to be at a risk of suicide and this was noted on the Controlworks log. Several admissions were made by GMP at the Inquest in relation to issues within the investigation and search for Mrs Partington. On receipt of the initial call at 13.34 hours the Radio operator placed an ACT marker on the vehicle Mrs Partington had taken and was thought to be in. This ACT marker was placed on the vehicle before the incident had been allocated and before the creation of a missing from home report. Hence the risk to the individual had not been assessed. When the missing from home report was taken Mrs Partington was deemed to be a medium risk. GMP accepted at the outset she should have been classed as a high risk. On the 8" August Mrs Partington’s vehicle “hit” ANPR cameras on two occasions. Firstly at 10.58am in the Rochdale area on the A58 and then at 16.36 hours on the A624 in Chuna! Derbyshire. GMP were not aware of the hit in Derbyshire until the 10 August 2019 when they searched the ANPR national system as opposed to simply conducting searches within the GMP area. When they did become aware they notified Derbyshire and requested an officer be deployed to this area to search for any signs of the vehicle. The vehicle was located within 2 hours of an officer being deployed and following a further search for Mrs Partington she was then located deceased in a nearby field. She had taken an overdose of her prescribed medication. She was located within 4 hours of a Derbyshire officer being allocated to search for her vehicle. An independent witness had seen her park her vehicle in this spot at 17.20 hours on the 8" August 2019. During the course of the Inquest the court heard about the differing levels of ACT marker which could be placed on a vehicle. In this case the level placed on by the radio operator was alow ACT. Asa result when Mrs Partington’s vehicle hit the ANPR in Derbyshire on the 8" August, Derbyshire police let officers know to be aware of this vehicle whilst they were attending other incidents. They did not as per policy inform GMP. If the vehicle had a medium ACT marker placed on it then Derbyshire would have informed GMP of the hit and also would have deployed an officer to the area to search for the vehicle on the 8"" August. GMP accepted that given the information known about Mrs Partington the level of ACT marker placed on the vehicle should have been a Medium ACT marker. GMP also acknowledged that radio operators within GMP did not check for national hits between the 8" and the 10" August. The court also heard evidence that it would normally be for the officer in the missing person case to request the Act marker. Having heard from several officers including the GMP specialist lead for missing persons it was clear to the court that operationally officers would ensure a marker was requested on the vehicle but beyond that, they would have little knowledge of the varying levels of ACT marker or the potential implications of the different levels. Evidence was given to the court explaining that in Derbyshire Constabulary a local system is in place whereby all medium ACT vehicles are created onto a “hot list’. This means that rather than officers having to proactively search local and national databases that a vehicle with a medium ACT marker would automatically be flagged up to the officer monitoring the ANPR. !f this had been in piace in GMP then the hit would have been automatically flagged up to officers on the 8" August 2019 negating the human error which occurred. It is understood from the evidence that a new national ANPR system has been commissioned which would have implemented such a system but the implementation of this has been delayed by some two years so far and is still not available in all forces, including GMP. 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:- 1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations. 2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8" August in both Rochdale and Derbyshire would not have been known at all. 3. Despite a new national system being available this has still not been implemented across all forces meaning a force is not automatically notified if a vehicle with a medium ACT marker hits an ANPR camera nationally. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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, namely 21* July 2021. |, 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- HE the daughter of Mrs Zeyna Partington. lam 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 from. 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. Date: 27:5.20a;
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.
Chief Constable Ms Joanne Kearsley HM Senior Coroner, Manchester North Newgate House Rochdale OL16 1AT GREATER MANCHESTER POLICE 16 July 2021 Dear Ms Kearsley Re Regulation 28 Report following the inquest into the death of Mrs Zeyna Partington Thank you for your report dated 25 May 2021 in respect of the tragic death of Mrs Zeyna Partington and pursuant to Regulations 28 and 29 of the Corners (Investigations) Regulations 2013 and Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009. Having carefully considered your report and the evidence submitted at the inquest, I make the following observations and recommendations to hopefully address your matters of concern. 1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations. The latest guidance governing the application and use of PNC markers is the College of Policing document entitled; ACT and React Reports on PNC. Version 1.6 was published and circulated to forces in March 2021. From my review, it seems that although a risk assessment process is included in the guidance document, it only includes one broad category of "Vulnerable Missing Person" and therefore could be interpreted that all missing person's vehicles should be afforded a Medium Priority Marker. The criteria outlined in the guidance for the use of High Priority markers states life must be at risk for them to be applied, but includes very limited examples such as "terrorism". There is no scenario in the guidance that suggests a Low Priority Marker is appropriate for a vulnerable or suicidal missing person. Similar to you, we share concerns that the way the guidance document is structured could potentially steer an officer only to apply a medium risk marker for every missing person, as opposed to utilising the High Priority marker when appropriate. This has been flagged by our Director of Intelligence who is already in liaison with the College of Policing and national lead for ANPR. Changes have now been agreed to the national guidance document which should alleviate this issue. It is my understanding that this work is very much underway already. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Changes have now been agreed to the national guidance document which should alleviate this issue. This work is very much underway. In addition to the above, internally we are in the process of reviewing and updating the GMP Missing From Home policy. Following your observations and recommendations and the changes to the national guidance, this will be updated to include more specific information on the use of ACT markers. This will include the expedient application of the correct level of marker in circumstances such as this case has highlighted. It will also include guidance on the use and review of markers and highlight expectations on the need for a timely response to activations. Although the content of the College of Policing guidance document on the use of markers and the Missing From Home policy are known to specific practitioners, the evidence presented at the Inquest into Zeyna Partington's death indicates there is a need to ensure increased awareness of the content across operational staff; specifically uniform frontline officers and staff from the operational communications branch. This will be addressed by a comprehensive communication plan which highlights the key changes to all relevant policy and guidance documents. Pertinent points will be identified, extracted and communicated to relevant officers and staff. Oversight will be provided via our Organisational Learning Board. I expect that the updated policies will be through stakeholder consultation, agreed and communicated to all relevant staff by the end of 2021. In the interim, key messages and learning will be cascaded immediately via my Chief Constables' order publication. 2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the Court heard, it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all. The updates to the Force Missing From Home policy will ensure that communications branch call takers ask specific and relevant questions in order to obtain early indicators of risk, in addition to identifying early investigative opportunities; such as the ownership and/or use of a vehicle by the missing person. The policy will be updated to require that a high priority ACT marker must be created as soon as practicable, following the receipt of information that suggests a missing persons' life is at risk and the details of any vehicle being used is confirmed. If that information is available when the first call is received by the Operational Communications Branch, then the expectation will be that the marker is created at that point. District supervisors managing the missing person investigation locally will also be expected to check that the appropriate marker has been applied for relevant cases. This will also be updated in the Missing From Home policy. 3. Despite a new national system being available this has still not been implemented across all forces meaning a force is not automatically notified if a vehicle with a medium ACT marker hits an ANPR camera nationally. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS The National ANPR Data Centre (NADC) is the system that was in use by both GMP and It is accepted that this Derbyshire Constabulary at the time Zeyna was reported missing. system has limitations and is in the process of being reviewed and replaced . Some UK forces have adopted the practice of listing vehicles of interest on the NADC via Cleartone which will then trigger alerts from all cameras nationally and send an automatic response within the system and to a nominated email address back in the originating force. This is something we are currently reviewing with support from experts across the region with a view to including it in our practice and in the updated version of our force ANPR policy. In relation to a longer term solution, the new National ANPR Service has now been deployed to the majority of the 43 UK forces with the exception of GMP and one other. We are working proactively to make improvements that will enable GMP to connect to the National ANPR Service in the near future. These changes include moving from Windows 7 to Windows 1O and undertaking comprehensive IT capability checks. We have a project team dedicated to this and they are in consultation with the Home Office in order to make progress as soon as possible. Determining an exact timescale for connectivity to the NAS involves a number of factors, several of which are outside of our control. Please let me know if you have any further questions. To reassure the Force is working hard to ensure that the lessons learnt from Zeyna Partington's sad death do change practice to help us improve the service we give to vulnerable missing people. Yours sincerely, Chief Constable Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
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