Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0263, written 3 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Aug 2021 |
|---|---|
| Reference | 2021-0263 |
| Deceased | Emma Day |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Police related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt. Hon Ms Priti Patel MP, Secretary of State for the Home Department, Home Office, 2 Marsham Street, London, SW1P 4DF, Broadway, London, SW1H 0BG, Metropolitan Police Service, The Rt. Hon Robert Buckland QC, Lord Chancellor and Secretary of State, Lord Chancellor's Private Office, Ministry of Justice,102 Petty France, London, SW1 9AH and Tribunals Service, 102 Petty France, London SW1H 9AJ Chief Executive (Acting), HM Courts and re First matter of concern. 2. The Rt. Hon Therese Coffey MP, Secretary of State for Work and Pensions, Department of Work and Pensions, Caxton House, Tothill St, London SW1H 9NA re Second matter of concern. 1 CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INQUEST On 1st June 2017, I opened an inquest into the death of Emma Day, who died on 26th May 2017 in the street April 2021. She died of multiple stab wounds and was Unlawfully Killed. . The inquest was concluded on 23rd 4 CIRCUMSTANCES OF THE DEATH There was a history of domestic violence from 2016 when Ms Day separated from her partner. He sent abusive text messages, which were reported to the police on 10th April and constituted an arrestable offence. She sought the advice and received support from the Gaia Centre. A Non-Molestation Order and a Prohibited Steps Order were issued but expired just before her murder. The police attempted one unsuccessful arrest enquiry and informed her they were not taking further action on 7th May. There was a clear history of coercive and controlling behaviour by the ex-partner known to Ms Day’s family, friends and work colleagues, but no agency had the full picture. On 1st November 2016 she applied to the Child Maintenance Service for maintenance, reporting the history of domestic violence. On 3rd November she asked that the claim be withdrawn as her ex-partner had threatened her life. On 16th May 2017 a Child Maintenance Options officer hears in a call that the applicant said that her ex-partner had been violent to her and had heavily implied that if she continued with the maintenance claim, her life would be in danger, but the threat to her life is not passed to the known CMS case worker, to whom Ms Day applies that day to get the claim reinstated. She is told by Ms Day that there had been domestic violence reported to the police and that the last claim had been cancelled as she was threatened by him. Staff were not fully and consistently trained in domestic violence. There was no action to address the potential escalation of the risk on reinstating the claim. 5 THE CORONER’S FIRST MATTER OF CONCERN 1. The Gaia Centre did not record the length or conditions of either the Non- Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated. 2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest. There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders. 3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned. 4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer. It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted, and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives. THE CORONER’S SECOND MATTER OF CONCERN The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence. a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim. b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted. c) A public body has an obligation to minimize risk when there is evidence of a threat to life. d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence, not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future, in particular on reapplying for maintenance. e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk. I concluded that staff would likely be uncertain of their duties. f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and the organizations to which this report is addressed will wish to know of these concerns and consider how far their actions have addressed the risks with regard to a) Disclosure of Orders and access to PNC and b) Protocols and training of Child Maintenance caseworkers. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 28th September 2021. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, 8 COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: (sister), Lambeth Social Services and Refuge/Gaia Centre. , (Standing Together Against Domestic I am also copying it to Violence), independent chair of Safer Lambeth Partnership Domestic Homicide Review, for information as he has an interest in the matter. I am also under a duty to send the Chief Coroner a copy of your response. He 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. 9 [DATE] [SIGNED BY CORONER] 3rd August 2021 Andrew Harris, Senior Coroner
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.
PROFESSIONALISM HQ
Senior Coroner Mr Andrew Harris
Southwark Coroners Court
1 Tennis Street
Southwark
London
SE1 1YD
Deputy Assistant Commissioner
New Scotland Yard
Victoria Embankment
London
SW1A 2JL
Date: 23rd September 2021
Dear Mr Harris
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the
Metropolitan Police Service (MPS) and I am responding on behalf of the Commissioner of
Police of the Metropolis to your Regulation 28 Report to Prevent Future Deaths, dated 3rd
August 2021. Your report was sent following the conclusion of the inquest into the death of
Miss Emma Day who sadly died on 26th May 2017.
The MPS has acknowledged and reviewed both matters of concern that you have raised and
have sought to address points 3 and 4 within your report.
The Metropolitan Police Service did not mention the Non-Molestation Order in the
Merlin Report, and when shared with Lambeth CSC only one of the children was
mentioned.
The Metropolitan Police Service (MPS) currently use the Missing Persons and Other Linked
Indices application (MERLIN) to report safeguarding and sudden death incidents. Once a
MERLIN report is created, it is sent to the MPS Multi-Agency Safeguarding Hubs (MASH)
where five year background research is completed to provide an informative intelligence
product with a risk assessment supported by a clearly recorded rationale. Research includes
checking the Police National Computer (PNC) and the Criminal Intelligence System
(CRIMINT). Non-molestation orders received from the courts, are now recorded on both PNC
and CRIMINT and should therefore be identified through research.
In June 2021, the MPS commenced a review of MASH with the strategic aim to improve the
identification of risk to both children and vulnerable adults across London, and to work in
partnership with statutory agencies to transform the collective response to information sharing
and collective assessment within the MASH teams. It focuses on a consistent and connective
approach to referral and agency activity which prioritises risk over volume; thereby improving
the safeguarding response to London’s vulnerable people. During this review, consideration
will be given to include details of non-molestation orders to be placed in MERLIN reports and
passed to partners so that they can be made aware and report any potential breaches.
As this review is a significant piece of work across all of London and has links to national work,
the review will take approximately 18 months to complete.
On 26th August 2021, communication was sent to all MASH sergeants asking them to place
details of any non-molestation orders found during their research, on to MERLIN before
sharing with the Local Authority and for this to be disseminated to all of their officers and
researchers. As a reminder, this communication will be followed up in a meeting with MASH
sergeants in September 2021 and included in the notes of the meeting that will be circulated.
With regard to the child who was omitted from the information shared with the CSC, we believe
this was a misunderstanding by the reporting officer that this information could be relevant.
However, on receipt of the report by MASH, the MPS MASH Resource Guide contains
information on how to complete a Research Template where there is a section to record
research on other family members. However, siblings will only be identified if they have been
listed on previous reports or on the report in question. When MASH identify siblings of the
subject, research should only be conducted on them if relevant and if required. Partners can
request further research on a subject at any point.
The Domestic Homicide Review recommended (R24) that the Home office work with the
Ministry of Justice to implement a system whereby protective orders can be input
directly to the Police National Computer. It was not clear whether all State Bodies that
needed to were able to make entries themselves on the Police National Computer
Conflicting evidence was heard, but one police officer stated that R24 had not been
adopted, and to do so would be welcomed by other agencies and that without this
change there might be missed opportunity to save lives.
PNC is the primary source of information for operational policing in the UK. Access to PNC
for non-police organisations can only be authorised by the Police Information Access Panel
which is made up of a cross section of senior Home office and police leaders who meet to
consider each application. Therefore, the MPS is not in a position to comment on whether
other agencies should be given permission to enter protective orders on to PNC.
The current process for receipt of judicial orders into the MPS is explained in the ‘Management
of Judicial Orders in the MPS Policy’. This states that on receipt of a judicial order, as a
minimum standard, the details should be recorded on the Police National Computer (PNC)
and Criminal intelligence System (CRIMINT). When an order is granted, it is the responsibility
of the officer in the case to ensure the order is recorded on PNC and a copy uploaded on
CRIMINT.
If the order relates to an automatic sexual notification requirement this will normally be
uploaded on to PNC by the Violent and Sex Offender Register (VISOR) Helpdesk.
If an officer is not present when a Judicial Order is granted at a criminal court, the Police
Liaison Officer will email a copy of the order to the officer in the case. If the order is granted at
a Family Court, for example a non-molestation order, then the court post or email a copy to
the MPS. If the subject of the order does not live in the Metropolitan Police District, then a
copy of the order should still be recorded on PNC and CRIMINT but also emailed to the
relevant force. Where there is no officer in the case, the order is scanned and forwarded to
the Central Specialist Crime Offender Management mailbox from which the details are entered
on CRIMINT and supplied to the Police National Computer Bureau for inclusion on the relevant
PNC record.
In Conclusion
I wish to express my sincere condolences to the family of Miss Day. The MPS is committed to
promote a culture of learning and continuous improvement wherever possible.
I trust this provides the reassurance that the MPS has considered the matters of concern you
have raised.
Please do not hesitate in contacting me should you have any queries.
Yours sincerely
Deputy Assistant Commissioner
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