Prevention of Future Deaths reports · 2021

Frankie Macritchie

Regulation 28 report to prevent future deaths, reference 2021-0315, written 17 Sep 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Sep 2021
Reference2021-0315
DeceasedFrankie Macritchie
CoronerAndrew Cox
Coroner areaCornwall and Isles of Scilly
CategoryChild Death (from 2015) · Other related deaths · Police related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Information Classification: CONTROLLED 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: The Dog Legislation Office, Devon and 
Cornwall Police Constabulary 

1 

CORONER 

I am Andrew Cox, HM Senior Coroner for the coroner area of Cornwall and the Isles of 
Scilly. 

2 

CORONER’S LEGAL POWERS 

3 

4 

I 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. 

INVESTIGATION and INQUEST 
On 17/9/21, I concluded an inquest into the death of Frankie Gray Macritchie, who died 
at Caravan 72, Tencreek Holiday Park in West Looe on 13/4/19. Frankie was 9 years 
old. 
 . 
The medical cause of death was recorded as: 
1a) Exsanguination 
1b) Multiple dog bites. 

I recorded a Narrative Conclusion that Frankie died from injuries inflicted in a dog attack. 

. 

, on holiday. They 

 owned a 5-year-old male 

CIRCUMSTANCES OF THE DEATH 
Frankie had gone to the caravan park with his mother, 
had joined a lady called 
American bulldog crossed with a Staffordshire bull terrier 
kilogrammes.  
Frankie was left unsupervised with the dog in the early hours of 13 April by his mother. 
He was attacked by the dog and died from the injuries he suffered.  
Subsequent investigations by the police have revealed the dog was involved in two 
incidents in October 2016 and a further incident in August 2018 when a child was bitten. 
While both incidents in 2016 were reported to police, it is believed that the incident in 
2018 was not.  
The obvious concern that came out of the inquest was that, had the incidents in 2016 
being investigated differently, this tragic outcome could have been avoided.  

. it weighed 45 

5 

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.  –  

-  That reports of dog attacks are fully investigated and, where appropriate, a dog 
is euthanised to try and reduce the risks of further and more serious incidents. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Information Classification: CONTROLLED 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 
[AND/OR your organisation] have the power to take such action.  

You may wish to consider the extent to which the reported dog attacks in 2016 were 
investigated. You may wish to take steps to ensure there is now a robust process in 
place that means all reported dog attacks are appropriately investigated and dealt with. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 14/11/21. I, 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: 
 [and to the LOCAL 
 and 
SAFEGUARDING BOARD (as the deceased was under 18). 

, 

I am 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 
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]       17/9/21         [SIGNED BY CORONER] 

2

Responses

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.

Response from Devon Cornwall Police (PDF)
Chief Constable 

Police Headquarters,  Middlemoor, Exeter,  Devon , EX2 ?HQ 

"101 Non-urgent 

0  DevonAndCornwallPolice 

"999 in an emergency 
a www.devon-cornwall.police.uk  ® dc_police.999 
9101@dc.police.uk 

O@DC_Police 

@ DCPolice 

Mr A Cox 
Senior Coroner 
Cornwall Coroners' Service 
The  New Lodge 
Newq uay Road 
Penmount 
Truro 
TR4  9AA 

22  November 2021 

Dear Mr Cox 

INQUEST  INTO  THE  DEATH  OF  FRANKIE  MACRITCHIE:  REPORT  UNDER 
REGULATION  28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

I  write  in  respect  of  the  above-mentioned  report  of  17  September  2021  ("the 
Regulation 28  report") that I have received from  you . 

Although  the  Regulation  28  report  was  addressed  to  our  Dog  Legislation  Office 
("DLO"),  I have decided  to  respond  to  it myself given the  nature of the  concerns that 
you have raised,  notwithstanding that this response has been compiled in consultation 
with the  DLO . 

Firstly,  I  would  like  to  express  condolences  on  behalf  of  myself  and  Devon  and 
Cornwall  Police to the family and  friends of Frankie. 

Secondly, I thank you  for sending  a copy of the  Regulation  28  report that was  made 
during  the  inquest  into  Frankie's  death.  As  you  would  expect,  I welcome  any  such 
opportunities  for  Devon  and  Cornwall  Police  to  consider  whether  there  are  any 
improvements that can  be made to  how we work. 

In  the  Regulation  28  report,  you  confirm  that the  matter of concern  that you  wish  to 
raise  is  one  of whether dog  attacks  are fully  investigated  and , where  appropriate,  a 
dog  is  euthanised  to  try  and  reduce  the  risks  of further  and  more  serious  incidents 
such  as  the  tragic  death  of Frankie.  You  also  suggest that  consideration  should  be 
given to: 

•  The  extent  to  which  reports  of  previous  attacks  by  the  dog 

  that 

attacked  Frankie were investigated. 

 
 ~ Devon & Cornwall 
'fj POLICE 

Chief Constable 
Police Headquarters, Middlemoor,  Exeter,  Devon,  EX2 ?HQ 

"101 Non-urgent 

"999 in an emergency 

O DevonAndCornwallPolice
O@DC_Police 

f) www.devon-cornwall.police.uk  @)  dc_police.999 

G)101@dc.police.uk 

~ DCPolice 

•  Taking  steps to ensure that there  is  now a robust process in  place that means 

all  reported dog attacks are appropriately investigated and dealt with. 

By way of context,  in  the first  instance  I will  outline  our general  position  in  respect of 
the investigation of reports to the police of an incident involving a potentially dangerous 
dog . 

Devon  &  Cornwall Police's investigation of dangerous dog  matters 

Reports  to the  police  of an  incident involving  a  potentially dangerous dog  commonly 
fall  into the following  categories: 

•  Dog  attacks on  people; 
•  Dog  attacks on  livestock; 
•  Dog  attacks  on  other animals  (for  example:  dog  on  dog  fights,  dogs  chasing 

cats etc);  and 

•  Offences involving  prohibited  breeds. 

The police response will typically vary depending on the type of report. 

I only intend to  give attention to the first category of allegation above in  this  response 
as the others do not appear to be relevant for the purposes of the Regulation 28 report, 
in that I am not aware that the police have ever received a report in  relation to the dog 
that attacked  Frankie that would fall within the scope of the other three categories. 

Where dog attacks on  people are concerned, a dog causing an  injury to a person while 
dangerously out of control represents an  offence under s.3 Dangerous Dogs Act 1991 
("ODA"). 

The police response to an allegation of such an offence depends on the circumstances 
of the  individual  matter;  for  example,  the  seriousness  of the  injury  caused  and  any 
previous offending  history involving the dog  in  question . 

Where an  allegation is  less serious in  nature,  and / or is the first allegation  of a minor 
s.3  ODA offence,  a  Dog  Control  Order ("DCO")  can  be  given to the owner of the dog 
in question by the police. A DCO is an agreement entered into by the owner of the dog 
on  a voluntary basis that is  not legally-binding whereby they agree to  keep the dog  in 
accordance with  various  requirements.  Common examples of such  requirements are 
requiring  the owner to  ensure that the  dog  is  muzzled  and  kept  on  a  lead  when  in  a 
public place. 

In the event of either a breach of a DCO, or more serious suspected s.3 ODA offences, 
the following  options are potentially available : 

•  An order that is similar to the DCO can be made by a court following a complaint 
by the police under s.2 Dogs Act 1871  ("the 1871  Act") . A breach of such order 

 
 t  Devon & Cornwall 

.  POLICE 

Chief Constable 
Police  Headquarters, Middlemoor, Exeter, Devon, EX2 ?HQ

~ 101  Non-urgent 

~ 999 in an emergency 
e www.devon-cornwall.police.uk  @) dc_police.999 
9101@dc.police.uk 

@DCPolice 

O DevonAndCornwal IPol ice 
O@DC_Police 

is  not in  itself a criminal  offence; however,  a breach  of an  order can  be treated 
as  a contempt of court which  is  potentially punishable by a fine  and  / or prison 
sentence.  The  order  can  also  be  made  as  a  contingent  destruction  order 
("COO"), i.e.  the  court can  order that the  dog  be  destroyed  if the  order is  not 
complied  with.  A  prosecution  does not need  to  have taken  place  for the  court 
to grant such  an  order. 

•  The  court can  also  make  an  order for the  destruction  of the  dog  under s.2  of 
the  1871  Act.  Again,  a prosecution  does  not  need  to  have taken  place for the 
court to  grant such  an  order.  When  making  an  order for destruction  under the 
1871  Act,  the court can  also potentially make an  order banning the owner from 
owning  dogs  in  the  future  under  supplementary  provisions  of the  Dangerous 
Dogs Act 1989 (rather than the similarly-named  1991  ODA) . 

•  The  owner  can  be  prosecuted  under the  ODA.  This  will  typically  be  pursued 
where  the  allegations  of  s.3  ODA  offences  are  particularly  serious  and  are 
accompanied  by evidence that makes out the offence to  the criminal  standard 
of proof. In other cases,  pursuing an order under the 1871  Act may well be more 
appropriate  as  the  court  can  make  such  an  order  on  the  basis  of the  civil 
standard  of proof.  A prosecution  under the  ODA can  result in  one or more of a 
fine,  imprisonment,  COO  and  / or destruction order being  ordered  by the court 
as  a part of their sentencing  powers. 

It  is  our experience that the  court will  only  make  an  order for destruction  in  the  most 
serious  of  cases,  and  typically  only  where  there  is  evidence  of  both  significantly 
irresponsible ownership and the dog  itself posing  a risk of harm . 

The  police  do  have  powers  under which  a  dog  can  be  seized,  and  any  decision  to 
seize  is  also  made  by  reference  to  the  individual  circumstances  of  the  matter  in 
question.  An  incident that is  assessed  as  being  more  serious and  / or one where the 
public are  believed  to  remain  at a risk of harm  from  the dog  is  more  likely to  result  in 
a seizure. The welfare of the dog  is also a potentially relevant factor. 

A  dog  that  is  believed  to  be  unregistered,  i.e.  not registered  in  accordance  with  the 
appropriate government dangerous dogs regime and a prohibited breed, will be seized 
regardless. 

It is my experience that there is a perception that the police are readily able to seize a 
dog  that  is  believed  to  be  dangerous  and  have  it  destroyed .  In  reality  this  is  not the 
case,  as  I have hopefully illustrated. 

Previous incidents involving 

As outlined above , the Regulation 28 report invites me to consider the extent to which 
reports of previous attacks by the dog that attacked  Frankie were investigated. 

I have been  made aware of two  reports to the police that are believed to be  in  relation 
to 

,  both  having been  received  in  October 2016 . These are as follows: 

 
 
 a 
u1 POLICE 

Devon & Cornwall 

Chief Constable 

Police Headquarters,  Middlemoor, Exeter, Devon , EX2 7HQ 

'-' 101 Non-urgent 

O DevonAndCornwallPolice

'-' 999 in an emergency 
0  www.devon-cornwall.police.uk  @) dc_police.999 

O@DC_Police 

Q101@dc.pollce.uk 

9  DCPolice 

•  A report of a dog that attempted to bite a member of the public. The subsequent 
enquiries by the police also revealed further suggestions that the dog  had  been 
intimidating  residents  local to where the dog  lived,  having  not been  kept under 
control  by  its  owner.  The  complainant  in  this  matter also  alleged  that the  dog 
had  previously barked and growled at her as she tried to  leave her vehicle. 
•  A further report of a dog running  loose in the road , in and out of traffic,  and after 

another dog . 

Both  reports  are  believed  to  be  in  relation  to 
indicates, we do not appear to  have received  any other reports in  relation to 

.  As  the  Regulation  28  report 
. 

In  relation to  both  incidents, enquiries were undertaken but ultimately the police were 
 had acted in a way that represented 
unable to identify definitive evidence that 
  was  given  words  of advice by  the  police 
an  offence;  therefore,  the owner of
about keeping the dog secure. 

These  incidents were concerning,  notwithstanding that no  physical  injury to  a person 
or  animal  was  alleged,  with  police  taking  action .  I  am  nevertheless  confident  that, 
between the seriousness of these allegations and the lack of evidence available to the 
police, that a prosecution for a s.3 ODA would not have been possible, nor would have 
an  application  for  a  destruction  order  (whether following  a  conviction  for  a  s.3  ODA 
offence or by complaint to the court under the  1871  Act) . In  short,  I am  confident that 
 destroyed would  have been  unsuccessful. 
any attempt by the police to  have 

It  is  arguable that the  dog  could  have  been  seized  by the  officers  dealing  with  these 
incidents,  but on  the  basis  of the  limited  evidence available  and  that these  incidents 
(even considered collectively) were  not among the more serious such reports that we 
receive  where  dangerous  dogs  are  concerned,  I  believe  the  decision  to  not  seize 

 was legitimate. 

It  is  also  arguable  that a  DCO  could  have  been  made,  or a  similar order applied  for 
under  s.2  of the  1871  Act,  in  response  to  these  incidents,  with  a  requirement  that 
 be kept under proper control.  I accept that these were options available to the 

police to  explore at the time. 

I am however confident that the contents of any such order would not be able to extend 
to  requiring  that 
  be  kept  in  accordance  with  any  requirements  in  a  private 
place.  It  is  our experience that such  an  order will  only  be  lawful  if it is  proportionate, 
i.e., no more than is  necessary to ensure that the dog in question is  kept under control, 
particularly where to go further could  represent an interference with the owner's Article 
8 rights under the Human Rights Act 1998. Notwithstanding that there was no definitive 
 posed  a serious  risk of injury to anyone available to the police, 
evidence that 
there  was  no  evidence at all  that he  was  out of control  in  a private  place,  i.e., where 
he  lived  or was kept. 

 
 1/9:;.-:  Devon & Cornwall 
~i~~  POLICE 
·... · 
·

Conclusion 

Chief Constable 
Pol ice Head quarters,  Middlemoor, Exeter, Devon , EX2 ?HQ 

O 101 Non-urgent 
0  999 in an emergency 
8  www.devon-cornwall.police.uk  @) dc_police.999 

O DevonAndCornwallPolice 
O@DC_Police

9101@dc.police.uk 

9  DCPolice 

I understand fully why you have raised this matter under a Regulation 28 report based 
upon the information  available to  you  at that time,  along  with  the terrible tragedy that 
resulted  in  the  death  of  Frankie. 
In  responding  to  your  direction,  undertakings  by 
operational and senior leaders including discussions with front line colleagues assures 
me that Devon and  Cornwall Police are dealing with reports appropriately where a dog 
poses  a  risk  of serious  harm.  On  the  basis  of these enquiries, I am  of the view that 
we deal with such reports robustly.  This includes having to defend our position through 
the courts and  the media. 

The police can  only successfully apply for the destruction of a dog  in the most serious 
of cases. Where  Frankie's tragic death  is  concerned,  I do not believe that the  police 
could  realistically  have  taken  any  steps  that  would  have  had  the  direct  result  of 
  being  destroyed  or  otherwise  kept  under  proper  control,  while  in  a  public 

place. 

As  you  would  expect,  correspondence  from  yourself is  taken  most seriously  by  me. 
Whilst I am  assured  in  regard to the specific questions you  raise , I have nevertheless 
taken this opportunity to  give further consideration to  how Devon and  Cornwall Police 
can improve our approach to the policing of dangerous dogs and potentially dangerous 
dogs with the public.  Whilst I am  satisfied as to our procedures,  I do perceive that the 
public do not always contact us and we are not always consistent in  making clear why 
and  how our decision making has taken place.  I will explore with the Police and Crime 
Commissioner the  opportunities for enhanced  public  communication,  potentially with 
our farming  community and  Local Authority partners in  respect of dangerous dogs. 

Thank  you  again  for  your  consideration  and  questioning  of the  force  through  the 
Regulation 28  procedure and  copying  the report to  me.  I trust this  response provides 
you  with  the further  information  that  you  require .  Please  do  contact  me  should  you 
wish for further clarification  or information. 

Chief Constable

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