Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0017, written 21 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2022 |
|---|---|
| Reference | 2022-0017 |
| Coroner | HH Judge Munro QC |
| Coroner area | East London |
| Category | Police related deaths · Other related deaths · Product related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
INQUESTS TOUCHING THE DEATHS OF ANTHONY WALGATE, GABRIEL KOVARI, DANIEL WHITWORTH AND JACK TAYLOR REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS ADDRESSEES 1 This Report is addressed to the following: (a) The Commissioner of Police of the Metropolis (b) The Chair of the National Police Chiefs' Council (c) The Chief Executive Officer of the College of Policing (d) The Secretary of State for Digital, Culture, Media & Sport CORONER 2 I am a Senior Circuit Judge in England & Wales sitting at the Central Criminal Court. I heard these Inquests having been appointed, for that purpose, as an Assistant Coroner in the coronial district of East London pursuant to Schedule 2 to the Coroners and Justice Act 2009 (“the CJA”). 3 My official address is The Central Criminal Court, Old Bailey, London EC4M 7EH. However, responses to this report should be sent to the Solicitor to the Inquests: , at Fieldfisher, Riverbank House, 2 Swan Lane, London EC4R 3TT. CORONER’S LEGAL POWERS 4 I make this Report on Action to Prevent Future Deaths under paragraph 7 of Schedule 5 (as given effect by Section 32) to the CJA and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (“the Regulations”). - 1 - THE INVESTIGATION AND INQUESTS 5 The Inquests to which this Report relates involved the deaths of four young gay men called Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor. All four young men were drugged with gamma-hydroxybutyrate (GHB) and murdered by a man called . Following a police investigation named Operation Lilford, was convicted by a jury of the four murders together with other offences involving the drugging and raping of living victims. 6 After my appointment to hear the Inquests, I held Pre-Inquest Review hearings on 5th July 2019, 15th November 2019, 10th July 2020, 24th September 2020, 20th November 2020 and 30th September 2021. The Inquests themselves commenced on 1st October 2021 and concluded on 10th December 2021. 7 At the Inquests, the jury determined that each of the four deceased had been unlawfully killed and, in each case, provided a supplementary narrative conclusion by means of answers to a questionnaire. Attached to this Report are copies of the Records of Inquest and completed questionnaires. 8 Further details concerning the Inquests, including transcripts of the hearings and copies of relevant rulings, can be found on the Inquests website: www.eastlondoninquests.org.uk. CIRCUMSTANCES OF THE DEATHS 9 A very full factual summary may be found in the transcript of my summing-up on 2nd and 3rd December 2021, which appears on the Inquests website. The following paragraphs of this Report provide a short summary to assist in consideration of the matters of concern raised below. 10 was a gay man who was, at the time of the killings, obsessed with drug rape pornography. would arrange to meet young men for sex via websites and apps such as Grindr, Bender, Fitlads and Sleepyboy. He would meet the young men at Barking station and take them to his flat at . There he would drug them with GHB and rape them while they were unconscious. In the cases of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor, the doses of GHB administered by killed them. 11 A young male who was referred to as “X1” was a former partner of . On 1st January 2013 he reported to police that had plied him with drink and “poppers” and anally - 2 - raped him the night before. He told police that there had been previous similar occasions. In the event X1 chose not to pursue the allegation, although he maintained that his version of events was true. Records containing this information were kept on the Police National Computer (PNC) and were available to access on the PNC. 12 In 2014, met up with a young male who was referred to as “X3” on a number of occasions. On 4th June 2014 and X3 were approached by British Transport Police at Barking station following a report that a male (X3) was being assaulted. X3 was clearly under the influence of drugs. account to the BTP was that they had met on the internet; that he had found X3 outside his house; that X3 had “taken G” and that he was going through X3’s bag to look for his phone. Records containing this information were available on the Police National Database (PND). 13 Anthony Walgate’s dead body was found two weeks later on 19th June 2014. Anthony had “met” (who had used the name ) via the Sleepyboy website. They arranged to meet up on 17th June. Anthony had provided his friends with details of the male he was to meet, an address and postcode and had shown them photograph. Anthony’s phone was last used at about 2200 when he was arriving in Barking. 14 At 0405 on 19th June, rang 999 and said that he had found a young boy collapsed in Cooke St. He did not give his name, but the number was soon traced to him, and police knocked on his door without success. Police found Anthony’s dead body slumped and propped up against a wall outside the entrance to address. The button on his jeans was done up but the flies were open and broken. He had no phone with him. 15 In accordance with police policy, a uniformed inspector attended, and the Homicide Assessment Team car (“the HAT car”) was called. It should be noted that Homicide Command was a specialist team of experienced murder investigators who were also known as Major Investigation Teams (MITs) and the Homicide and Serious Crime command (SC&O1). There are a number of policy documents, including the Murder Investigation Manual, which set out for all police officers the approach to be taken to a sudden unexpected death. For present purposes it is sufficient to note that the HAT car should be called to any suspicious death. I shall return to the terminology in due course. 16 That morning police took a statement from in which he told a pack of lies in relation to finding Anthony’s body upon his return from work at around 0400. - 3 - 17 Anthony’s friend, , went to police on the evening of 19th June and gave police the details of and his description. 18 A Special Post Mortem was held on 20th June. MIT and Borough officers attended. The findings were consistent with drug use/overdose, but no cause of death could be ascertained, and samples were sent for toxicology. It was noted that Anthony’s pants were on inside out and back to front and that he had bruising under his arms. He was wearing a T- shirt which was much too big for him. On 10th September 2014, the toxicology results came back and showed that Anthony had died of an overdose of GHB. 19 By 25th June, police knew that had lied to the police about the circumstances by which he found the body and that a PNC check had revealed the previous allegation of rape. 20 was arrested on 26th June for Perverting the Course of Justice. He was interviewed and volunteered a completely different version of events in which he eventually admitted he had met Anthony for sex. When asked by the interviewing officer why he had not left Anthony in his bed and called 999 replied that he thought it “would look suspicious like last time” (referring, it later emerged, to the incident with X3 about which the police were still unaware). After that interview police knew that had spent the last 36 hours of Anthony’s life with him and lied about it. Thereafter the Borough Officers were asking SC&O1 to take primacy for the investigation. 21 Detective Superintendent of SC&O1 declined to take primacy but indicated that he would keep the matter under review and offered a team of MIT officers to assist with the investigation on the Borough. He did not communicate this decision directly to the Borough team. Nor was there ever any review. Mr was not fit to give evidence at the Inquests and could not be asked about his decisions. 22 MIT officers interviewed on the 27th June 2014. In that interview he gave information about the X3 incident, but this was never followed up by the police and so they remained unaware of the information contained in the PND record about the incident. Following his interview on 27th June was charged with perverting the course of justice and released on bail. 23 On 18th August Gabriel Kovari “met” on Fitlads. At that time Gabriel was renting a room from a man named , but was looking to move out. Gabriel moved into flat on 23rd August 2014. He sent his friend photos taken inside - 4 - flat and a pin drop of the location. He called his former landlord and friend using a phone belonging to an acquaintance of his called . introduced Gabriel to his friend on 24th August. Gabriel was drugged and murdered by on 25th August. Thereafter changed his phone number. 24 At 0900 on 28th August, a dog-walker named found Gabriel’s body in St Margaret’s churchyard, 400 yards from flat. He was in a similar position to that in which Anthony had been found with his clothes rucked up. He had all his possessions with him but no phone. Paperwork was found containing address. The death was declared non-suspicious. 25 was told of Gabriel’s death and immediately set about trying to find out what had happened. He tracked down the male whose phone Gabriel had used, . told police that Gabriel had moved to Barking and that his Facebook name was . 26 On 1st September, he also contacted Gabriel’s partner, , and exchanged information with him. 27 The post mortem findings in Gabriel’s case were consistent with ingestion of drugs. Samples were sent for toxicology. The results came back on 7th October and indicated fatal levels of GHB. 28 On 8th September 2014 made a statement in which he said that he had been in contact with who had told him that Gabriel had been seeing two Black men: and a man named . 29 On 10th September a male calling himself ” posted on Gabriel’s Facebook. Thereafter “ messaged frequently with , purporting to give information about Gabriel. was, unbeknownst to anyone at that stage, . 30 After the Walgate toxicology results were received, on 10th September, DI asked that the matter be referred back to the MIT. That referral never took place. 31 Daniel Whitworth was in a long-term relationship with . He had been in social media contact with since August 2014. On 18th September 2014 he arranged to meet in Barking and did so. Daniel was drugged with GHB and murdered by ; his body was discovered on 20th September. Thereafter, laid a false trail on - 5 - Facebook in which he indicated that Gabriel had met up and gone off with “ ” to a chemsex party. 32 found Daniel’s body in exactly the same location and in an identical position as she had found Gabriel’s, at about 1120 on Saturday 20th September 2014. Daniel was holding what purported to be a suicide note which was contained in a plastic sleeve. The note indicated that the author had “taken the life of” his friend, “ ” “at a mate’s place” and also referred to having had sex with a male “last night”. It went on to say that he, Daniel, had just taken an overdose of GHB and sleeping pills. Like Anthony and Gabriel, Daniel had no phone on him. He was wrapped in a blue bed sheet. With him was a table mat. He had a small brown bottle in his pocket which was similar to one found with Anthony. 33 The HAT car was called, and a Special Post-Mortem arranged. The pathologist found bruising under the arms and to the front of the chest and, he said, recommended orally that the sheet should be sent for forensic examination. No cause of death was ascertained and, again samples were sent for toxicology. 34 A fragment of the note was emailed to Daniel’s father the day after he had been informed of his son’s death, swiftly followed up by a telephone call asking him if it was Daniel’s handwriting. Daniel’s father’s evidence at the Inquests was that he had said he couldn’t be sure; the officer who spoke to him on the phone said that he had confirmed to her that it was Daniel’s writing. From then on, the note was treated as authentic. 35 The toxicology results came back in November 2014 and, again, revealed a fatally high concentration of GHB in Daniel’s body. The final post-mortem report was not sent to the police until April 2015, yet, prior to receiving it, the investigating officers closed the investigation down. 36 was charged with Perverting the Course of Justice on 27th January 2015. He pleaded guilty and was sentenced on 23rd March 2015 to a period of imprisonment from which he was released on 4th June 2015. 37 CCTV showed that Jack Taylor met up with at around 0245 on 13th September 2015 having made contact with him on Grindr in the early hours of that morning. His body was found against a wall of the same churchyard as Gabriel’s and Daniel’s bodies had been found the year before and in a similar position. He too had no phone. With his body was a small phial of what turned out to be GHB, as well as a syringe (unused), some white - 6 - powder and a tourniquet. The scene had been staged to make it look as if Jack had taken a drug overdose. It was by chance that was identified as the male in the CCTV whom Jack had met in Barking during the night on 13 September. His identification occurred on 14th October 2015 when DC , an officer from the Anthony Walgate investigation, happened to speak to PC as she was looking at an image of the CCTV — and he recognised . It is noteworthy that despite the link then having at last been made SC&O1 still did not, at that stage, take primacy; it was not until the following day that SC&O1 accepted primacy. LEGAL PRINCIPLES 38 A Coroner comes under a duty to make a Report (CJA 2009, Schedule 5, para 7) where: (a) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur or will continue to exist in the future; and (b) In the Coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. 39 A Report in this context is a report to prevent other deaths (Coroners (Investigations) Regulations 2013, Reg 28). 40 If these conditions are satisfied the Coroner must report the matter to “a person who the coroner believes may have power to take such action” (CJA 2009, Schedule 5, para 7). 41 The following features, which emerge from the Regulations, the caselaw and from the Chief Coroner’s Guidance No. 5 Reports to Prevent Future Deaths, are, in my view, relevant: (a) A Coroner must not make a report until he or she has considered all the documents, evidence and information that in his or her opinion are relevant to the investigation (Reg 28(3)). (b) The concern regarding risk of future deaths may be generated by anything revealed by the investigation and is not therefore limited to concerns arising out of the evidence heard or read during the inquests (para 10(2) of the Chief Coroner’s Guidance No. 5). - 7 - (c) The power and the duty to make a Report arises where the Coroner has concern that circumstances creating a risk of further deaths will occur, or will continue to exist, in the future; this is a matter for the discretionary judgment of the Coroner (R (Cairns) v HM Deputy Coroner for Inner West London [2011] EWHC 2890 (Admin) at [74]). (d) The report need not be restricted to matters causative (or potentially causative) of the deaths which have been the subject of the inquest(s), but it must nevertheless be concerned with circumstances which create a risk of other deaths (para 17 of the Chief Coroner’s Guidance No.5; Lewis (cited above) at [14]-[19]; Rule 43 Report of Hallett LJ following the London Bombings Inquests, [161]; R (Francis) v HM Coroner for Inner South London [2013] EWCA Civ 313 at [7]-[8], Davis LJ). (e) The regime provides for a Coroner to make a report if he or she forms the opinion that a risk of future deaths can be identified, and that preventive action ought to be taken in all the circumstances. If he or she forms that opinion, it is necessary to make a report articulating his or her concerns. That is the effect of the words “must report” in paragraph 7(1). See R (Lewis) v Mid and North Shropshire Coroner [2010] 1 WLR 1836 at [14]-[16] and [19]. As Silber J said in R (Cairns) v HM Deputy Coroner for Inner West London [2011] EWHC 2890 (Admin) at [74], the statutory expression “in the coroner’s opinion, action should be taken…” reflects a discretionary judgment by the Coroner. (f) It is not for the Coroner to suggest what remedial action should be taken; his or her role is to express clearly and simply and in ‘neutral and non-contentious terms’ the specific factual basis for her concern(s) and nothing more (paras 23-27 and 31 of the Chief Coroner’s Guidance No. 5). 42 In addition, paragraph 2 of the Chief Coroner’s Guidance No.5 on Reports to Prevent Future Deaths states: “These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.” 43 It is also right to recall that an important element of the Article 2 duty in both domestic law and the law of the European Convention on Human Rights is the identification of systemic failures and risks. See, for example R (Amin) v SSHD [2004] 1 AC 653 at [31]; - 8 - R (Sacker) v West Yorkshire Coroner [2004] 1 WLR 796 at [11]. The domestic legal scheme deliberately confers on a professional adjudicator (the Coroner) the judgment whether such risks exist and whether they need to be addressed by action: see Lewis (cited above) at [40]; R (Middleton) v West Somerset Coroner [2004] 2 AC 182 at [38]. 44 A Coroner may properly decide not to make a PFD report on an issue on the basis that he or she is not satisfied that further action is necessary. If, for example, it appears that a risk or issue has been addressed by action of some kind, or if circumstances have changed substantially since the death in question, the Coroner may reasonably say that he or she is not satisfied further action is required. Equally, a Coroner may decide that there is simply insufficient material to form a view that there are particular risks of future deaths and/or that further action is required. See, for example, the approach taken by Hallett LJ to various issues in her Rule 43 Report after the London Bombings Inquests (e.g. [70] and [217]). See also Jervis on Coroners (14th ed.) at [13-125]. 45 PFD reports are important, but they are ancillary to the inquest procedure and not its mainspring. See the Chief Coroner’s Guidance No. 5 at [6] (and see, to the same effect, Dove v HM Asst Coroner for Teesside [2021] EWHC 2511 (Admin) at [73]). 46 Broadly speaking reports should be intended to improve public health, welfare and safety. They should not be unduly general in their content; sweeping generalisations should be avoided. They should be clear, brief, focused, meaningful and, wherever possible, designed to have practical effect. See the Chief Coroner’s Guidance at [4]. 47 If a report is made, it need not (and generally should not) prescribe particular action to be taken. It need not (and generally should not) apportion blame or be prejudicial (see, to the same effect, Jervis at [13-123]). The content of the report should be focussed and limited to the statutory remit. See Guidance at [27]-[30]. 48 In summary: (a) A Coroner should make a PFD report if satisfied of two propositions: (i) that there is a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future; and (ii) that in his or her opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. Each of these issues, especially the second, is a matter of judgment. - 9 - (b) The Coroner must form this judgment based on information revealed by the particular coronial investigation. It is not necessary for the Coroner to conclude that the particular death under investigation was caused by the circumstances or risks which may be the subject of the report. However, it is usually necessary for the Coroner to find that general or systemic risks or failures have been highlighted by the material in the particular investigation. (c) It is perfectly proper for a Coroner to say that a risk or issue has apparently been addressed, or that on the available material he/she cannot be satisfied that preventive action need be taken. In making a decision, the Coroner is entitled to take account of the passage of time and changes of circumstances since the deaths. (d) Before deciding whether to make a report, the Coroner should consider whether it would be directed to improving public health, welfare or safety and whether it would be focussed, practical and within the statutory remit. 49 Finally, it is important to note that PFD reports will standardly draw attention to matters of concern or to risks, rather than prescribing particular solutions. A Coroner is often not qualified to propose specific action and may not be aware of all the consequences of taking such action. A Coroner may be unaware of exactly what remedial action is practicable, or unaware of competing demands for resources. These considerations should not, of course, lead to paralysis in the preparation of PFD reports. A Coroner may raise a concern and later be properly told that there is no perfect or practicable solution. 50 Naturally much of the evidence in the Inquests focused upon the police, both the local Barking and Dagenham Police and the pan-London Homicide Command, SC&O1. Paragraphs 55 - 90 below focus on concerns that I have regarding policing matters. Paragraphs 94 – 97 deal with a point of concern relating to the Sleepyboy website. CORONER’S CONCERNS 51 The evidence that I have received during my investigation, including the evidence given during the course of the Inquests, has revealed matters which give me cause for concern. 52 In my opinion, there are risks that future deaths could occur unless action is taken to address those risks. In these circumstances, it is my statutory duty to report my concerns to appropriate persons who may be able to take remedial action. This Report covers - 10 - various topics and sets out matters of concern which are being reported to the addressees. Each matter of concern is denoted by an “MC” reference and is highlighted in bold. In each instance, those to whom the point is addressed are identified. In total there are some nine matters of concern detailed below: eight of those are about policing matters, and fall within five topic areas. The ninth matter of concern is about the Sleepyboy website. 53 In preparing this Report I have taken into account submissions from the bereaved families identifying matters that they invite me to treat as matters of concern, as well as submissions in response from other Interested Persons. 54 As well as identifying and explaining matters of concern, this Report also addresses some points raised by the bereaved families which do not, in my view, justify inclusion in my PFD Report. It is not normal practice for coroners to provide in their PFD reports a detailed account of matters raised by Interested Persons or to engage in an explanation of why certain matters raised are not included as matter of concern. PFD reports of coroners generally are, and should continue to be, short and succinct documents produced quickly after inquests. This Report by contrast, and with the approval of the Chief Coroner, is a more extensive document, as is appropriate to these exceptional inquests (just as Hallett LJ produced a lengthy PFD report following the London Bombings Inquests, and just as HHJ Lucraft QC did after the London Bridge, Borough Market Terror Attack and Fishmongers’ Hall Inquests). It should not be seen as a model for inquests generally. MATTERS OF CONCERN: POLICE Overarching considerations 55 There are a number of aspects of these Inquests which I have considered before preparing this PFD Report, and which I wish to address in this overarching considerations section of my Report before I move to the section of my Report that sets out individual matters of concern. 56 Perhaps the most striking of these is the large number of very serious and very basic investigative failings, described by DAC as “a series of errors, lack of curiosity, failings”, and about which he said he had “never quite seen anything as unique […] and as having such terrible consequences as we have been discussing through this inquest.” I have been extremely concerned and disappointed by the evidence that I have heard about these series of errors. - 11 - 57 It is also right to recognise, however, that the investigations took place in 2014-2015 and that a serious effort has been made by the Metropolitan Police Service (“MPS”) since that time to identify what went so wrong, to identify the causes of those failures and to take steps to improve the organisation in what, I accept, are very real ways. Those efforts are ongoing; the most recent being a working group which has been set up by the MPS Head of Homicide to examine a number of features of the functioning of the BCUs and the MITs when investigating deaths, as well as the wording of the relevant policies. 58 That said, and notwithstanding those efforts, there are some matters that I consider justify a PFD report, which I set out below. 59 Before turning to those, I wish to address four, more general, issues. 60 First, lack of professional curiosity. This is a phrase which has been used to try and capture what lay at the root of many of the individual errors and oversights. DAC observed in his evidence that the “A, B, C of policing [is] accept nothing, believe no-one, challenge everything”, yet time and again I heard evidence of officers lacking the curiosity and motivation to investigate and find out what had actually happened to these young men whose bodies were found in Barking. I do acknowledge that DAC has provided evidence of how the MPS as an organisation has tried to tackle this, and so I am not raising it as a formal matter of concern. But, because it played such a central part in the events examined by these Inquests, and because it was a concept which resonated through the first three Inquests, I do wish to place on record my view that this is a key lesson from these Inquests that should be borne in mind both by the MPS, and nationally. 61 Second, misconduct procedures against individual officers. The Families represented by have submitted that I should enquire, in relation to a number of identified serving police officers, whether they have undergone unsatisfactory performance procedures. The Families further submit that, if not, or those procedures have not led to objective performance improvements, then I should make a PFD report regarding the performance of those individual officers. Such a PFD report would need to be addressed to the Independent Office for Police Conduct (“IOPC”) inviting it to consider exercising its power under s.13B of the Police Reform Act 2002. I do not consider that the evidence regarding specific errors made by individual officers in these circumstances engages my duty under CJA 2009, Schedule 5, para 7 and therefore misconduct procedures - 12 - against individual officers is not an issue which I address further below in the body of the section of my Report that sets out the issues which I identify as matters of concern. 62 Third, despite my view that disciplinary proceedings in relation to individual officers should not form part of my PFD report, I do wish to record and draw to the IOPC’s attention my observation that the evidence heard in these Inquests has exposed failings which were not identified by the IOPC in their investigation. I note in that regard that the IOPC Regional Director has stated that the IOPC is assessing whether to reopen — either in full or in part — its investigation into the way the MPS handled inquiries into the four deaths. 63 Fourth, Dr on behalf of , Daniel’s partner, has invited me to make a PFD report requiring the MPS to consider conducting a review into whether the investigations into these four deaths was impacted in any way by prejudice. Having concluded that it would not be safe or fair on the evidence that had been heard to leave the issue of prejudice to the jury I am not going to make a PFD report on this issue as invited. I do, however, agree with the statement at paragraph 254 of the IOPC’s independent learning report Operation Wasabi (a report on the learning opportunities arising from the initial police investigations into the murders) that “the possibility of assumptions being made about the lifestyle of young gay men and the potential vulnerability of men cannot be ignored, and may reveal that intersectionality was present in policing in 2014/2015, and may still be”. I note that the Mayor of London has asked Her Majesty’s Inspectorate of Constabulary, Fire and Rescue Services to conduct an independent inspection into the standards of investigations carried out by the MPS in this case, and that of Blackstock is also conducting an independent review into the standards of behaviour and internal culture of the Metropolitan Police. I would commend the IOPC’s Report to HMICFRS and as containing a valuable analysis of how assumptions, stereotyping and unconscious bias may have detrimentally affected the decision-making in these investigations and contributed to the failure to identify as a perpetrator sooner. Topic 1: Categorisation of suspicious, non-suspicious and unexplained deaths 64 At the time of the police investigations into the four deaths there were a number of policies in place which set out the principles to be observed by officers investigating sudden unexplained deaths, one salient example being the ACPO Murder Investigation Manual. - 13 - The Murder Investigation Manual advised that it is sometimes difficult to determine whether a particular death is a result of natural causes, an accident, suicide, or homicide; the Manual stipulated that, where there is uncertainty as to the nature of the death, the police must investigate as if the death were a homicide “until the evidence proves otherwise”. However, notwithstanding this guidance, the evidence I heard was that SC&O1 were reluctant to take on the investigation of Anthony’s case because of the lack of evidence that he had been killed — his death was accordingly described as “unexplained”; that within five hours of the discovery of his body, Gabriel’s death was classified as “unexplained but not suspicious” (in circumstances where, as the Duty Inspector accepted in evidence, he “had no idea” how Gabriel had died), and in the days that followed there was very little by way of investigation into his death, and on the day of the discovery of Daniel’s body his death was classified as “non-suspicious” by the duty inspector, and readily accepted as a suicide despite a total failure to establish that Gabriel and Daniel in fact knew one-another, or indeed had been together the night before Gabriel’s body was discovered, as the note suggested. 65 The ACPO Murder Investigation Manual has been replaced (as of November 2021) by the NPCC Major Crime Investigation Manual. The current NPCC Manual does not use the term “unexplained”, but other current policies do, for example, the MPS Death Investigation Policy (24 May 2021). 66 The evidence I heard revealed that, despite the policy in force in 2014-2015 stipulating that the police should “think murder” and treat a sudden death as suspicious until satisfied that it was not, the officers investigating the sudden deaths of Anthony, Gabriel, Daniel and Jack allowed themselves to categorise these deaths as “unexplained”, rather than establishing, through investigation, a satisfactory explanation of the circumstances of the death. 67 I was told by DAC in evidence, and by the MPS in correspondence, that a working group has been set up by the MPS Head of Homicide to consider various aspects of the interaction between the BCU and the MIT. I understand that one of the issues that the working group has been considering is whether the MPS policies relevant to the investigation of deaths would benefit from amendments to their wording to make clear what is meant by “unexplained”, “suspicious” and “non-suspicious”. I was told in a letter from the MPS dated 6th January 2022 that “newly drafted material” prepared by the working group exists in draft form, but has not yet been finalised. - 14 - 68 It is a matter of concern that although the current MPS policy, the Death Investigation Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a sudden death should treat the scene and incident as suspicious until satisfied that it is not, the term “unexplained” as used in the current policy may once again distract officers from the correct and necessary approach, which is for the death to be treated as suspicious unless and until the police investigation has established that it is not (MC1). 69 MC1 is addressed to the Commissioner of Police. Because this concern is likely to be relevant not only to the MPS, but also to policing nationally, I also address this concern to the Chief Executive Officer of the College of Policing and the Chair of the National Police Chiefs' Council. Topic 2: the interaction between specialist homicide investigators and BCU officers When primacy is taken by the specialist homicide investigators 70 One of the central issues in the Inquests was that of “primacy”. Primacy refers to ownership of an investigation: the investigation team which owns and is responsible for the investigation is the team that has primacy. The MPS policies at the time stipulated that SC&O1 should have primacy for homicide investigations, that is to say the investigation of deaths where a third party has been involved (e.g. murder and manslaughter). Other deaths — where there was no third-party involvement — should be investigated by local CID officers; the Borough officers would, in these cases, retain primacy. As it would be the local Borough officers who would be first apprised of a sudden death, it would be for them to contact SC&O1 to ask for the MIT’s involvement, and SC&O1 would decide whether or not to assume primacy, and if the decision was not to take primacy, whether and to what extent the MIT would provide specialist advice and assistance. 71 The Inquests heard a lot of evidence about the interaction between the Borough officers and the SC&O1 officers regarding primacy. In Anthony’s case the evidence was that the Borough officers, including at Chief Superintendent level, wanted SC&O1 to take primacy for the investigation because it appeared to them that , in whose flat Anthony had been for the last 30 hours of his life, was probably involved in his death, and that they did not have a PIP3 accredited detective (i.e. a qualified homicide detective) within the Borough CID to lead the investigation. In Gabriel and Daniel’s cases the note found with Daniel’s - 15 - body said that he, Daniel, had “taken the life of” his friend, Gabriel, “at a mate’s place”, which prompted the Superintendent at Barking Borough to consider that SC&O1 ought to take primacy. 72 Thus in Anthony’s case the Borough officers communicated to SC&O1 that it was likely that a third party ( ) had been involved in Anthony’s death. In Daniel’s case the note found at the scene stated that a homicide had occurred. Yet with both of these deaths SC&O1 declined primacy. The evidence of the Detective Sergeant in Anthony’s case was, in my view, telling. He said that “sometimes you can have quite a strange conversation with someone from homicide command where they would say, ‘But you cannot prove it is murder’, but then that is what the investigation is for. You cannot prove it is murder until you investigate it.” 73 Those policies have since changed. The current MPS policies include the Death Investigation Policy (designed to provide guidance for the investigation of sudden death by first responders, the most recent version of which is dated May 2021) and the Homicide Policy (designed to provide guidance for the investigation of suspicious or unexplained deaths, the most recent version of which, I understand from Temporary Detective Superintendent witness statement, is July 2020). The content of the current MPS Death Investigation Policy (May 2021) has in fact been informed by, inter alia, the recommendations emerging from a review of GHB related deaths that the MPS undertook as a direct response to the discovery that had been responsible for these four deaths. As with the policies in place in 2014-2015, the current Death Investigation Policy stipulates that the Specialist Crime Command or SCC (the replacement for SC&O1) will have primacy for the investigation of suspected homicides and unexplained deaths in suspicious circumstances. But DAC told me that having heard the evidence that had been given to the Inquests he considered that the current Death Investigation Policy was not clear. He said that, notwithstanding the fact that a decision on primacy will always be a matter of individual judgment, the policy framework needed to be clearer; I concur. 74 I understand from that the letter from the MPS dated 6th January 2022 that the working group chaired by the Head of Homicide is currently considering whether any changes, not only to policies, but also training and/or guidance, are necessary. The working group is due to deliver its conclusions early this year. - 16 - 75 In the context of these unexplained deaths, which were extremely challenging to investigate, SC&O1 — the specialist homicide investigators — were reluctant to take primacy. It is a matter of concern that the current policy framework guiding decisions on primacy still lacks clarity (MC2A). 76 MC2A is addressed to the Commissioner of Police, and also, because of its potential national implications, to the Chief Executive Officer of the College of Policing and the Chair of the National Police Chiefs' Council. Support for BCU officers where specialists do not take primacy 77 Although SC&O1 did not accept primacy for the investigations into Anthony’s, Gabriel’s or Daniel’s deaths, the MIT did provide support to the Borough officers. However, a further important issue about which I heard evidence was the nature and quality of that support, which at times was, in my opinion, unsatisfactory. By way of examples from the investigation the MIT detectives who interviewed did not identify lines of enquiry arising, or provide advice as to how to progress the investigation following the interview — they simply conducted the interview, made handwritten notes and left Barking; the MIT inspector who had been tasked to “ensure that nothing is missed” in Anthony’s case did not actually physically attend the Borough police station as had been envisaged; the MIT did not, it would seem, carry out intelligence checks that the documentary evidence from the investigation suggested they had undertaken to do. Further examples from the investigation are that the MIT detective who attended Daniel’s special post-mortem did not record the pathologist’s de-brief, and did not seek and record the pathologist’s views on the police theory that the bruising under Daniel’s arms had been caused by rough sex. 78 It is acknowledged that much has been done to improve the level of support that the specialist homicide investigators and forensic practitioners provide to BCU officers where primacy remains with the latter, for example with the introduction of specialist crime hubs which integrate, by geographical area, specialist homicide investigators with CID officers, and with the more active role now taken by crime scene managers in BCU-led cases. Indeed, the ongoing role for MITs where primacy is refused is a further matter which is currently being considered by the working group. However, it remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be - 17 - expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU (MC2B). 79 MC2B is addressed to the Commissioner of Police, and also, because of its potential national implications, to the Chief Executive Officer of the College of Policing and the Chair of the National Police Chiefs' Council. Topic 3: Leadership 80 The evidence that I have heard at these Inquests has led me to conclude that the leadership and supervision of Borough investigations at Detective Inspector and Detective Sergeant level was inadequate, which led to basic errors and oversights in the investigations not being identified and/or corrected. Some examples include the failure to conduct basic intelligence checks on on the Police National Database; the failure to get laptop examined; the failure to review the downloaded contents in a targeted fashion once it had been provided on a USB stick; the failure to obtain phone data relating to Daniel’s phone for the dates around Gabriel’s death, the failure to appreciate the significance of evidence as to Daniel’s whereabouts on the evening he was supposed to have killed Gabriel and the various failures to take and/or submit forensic samples. 81 I also heard evidence from the Detective Inspector who was responsible for providing the closing reports for the Coroner for the investigations into Gabriel’s and Daniel’s deaths. He accepted that his reports contained serious material inaccuracies. This also is, in my view, an example of leadership having failed. 82 A lack of leadership was, likewise, one of the major factors identified by DAC when he was asked to explain what he thought had led to the multiple failures in these investigations. More effective leadership might well have meant that other basic errors or oversights would have been corrected, such as the failure to obtain the critical intelligence on that was there to be found, and the delay in getting laptop examined. It is a matter of concern that despite the regularly refreshed training that is now in place for detective sergeants and detective inspectors, and the additional leadership training in which the MPS has invested, a lack of ownership and responsibility for - 18 - the investigations of unexplained deaths may persist in officers who are supposed to be leading investigations into unexplained deaths (MC3A). 83 MC3A is addressed to the Commissioner of Police, and also, because of its potential national implications, to the Chief Executive Officer of the College of Policing and the Chair of the National Police Chiefs' Council. 84 In his evidence DAC agreed that one core role of leaders in police investigations is periodically to “take a step back” and undertake a review of the investigation to assess what progress has been made, and how the investigation should profitably proceed. DAC told me that there is a Specialist Crime Review Group within the Metropolitan Police which Barking CID could have asked to assist with the question of whether there was any link between the deaths; DI evidence to me, however, was that in 2014 he was unaware of the SCRG’s existence, and that, in any event, the SCRG in his experience rarely worked with local investigators. I understand that since the conclusion of the Inquests the MPS has taken steps to further publicise the existence of this group by widening the circulation list of the SCRG newsletter. It nevertheless remains a matter of concern that the SCRG, which DAC commended as an asset to assist in the process of review of complex investigations is not, in practice, accessible and/or properly understood as a resource (MC3B). 85 MC3B is addressed to the Commissioner of Police and also, because of its potential national implications, to the Chair of the National Police Chiefs' Council. Topic 4: Use of the CRIS / new CONNECT system 86 DAC explained that the new MPS Death Investigation Policy requires that all sudden or unexplained death investigations are to be recorded on the MPS Crime Report Information System (CRIS) as a crime related incident. This is to be welcomed, but I note that, on the evidence heard at these Inquests, even when a CRIS was used to manage an investigation (in Anthony’s case, for example), it was not used properly with investigative actions being set, and outcomes recorded to allow all involved to understand the progress of the investigation. I understand from the MPS submissions that the new CONNECT system (which at the time of writing has not yet been introduced) displays outstanding actions in a clearly visible fashion. However, it remains a matter of concern that whatever the system, CRIS or CONNECT, officers may not record lines of - 19 - investigation, actions and outcomes (MC4A). A further, related, matter of concern is that the CRIS was closed by supervising officers without any review of whether the actions had been completed or any critical assessment at detective sergeant level or detective inspector level of whether the investigation had established that the death was non-suspicious (MC4B). DAC told me that he “simply could not fathom” why this happened. I have been told by the MPS in their submissions that numerous steps have been taken to improve the conduct of supervisors; I commend this, but encourage the MPS to consider whether there is anything further that might be done to address the concerns I have expressed above. 87 MC4A and MC4B are addressed to the Commissioner of Police of the Metropolis. Topic 5: Verification of handwriting 88 The handwritten note found in a plastic sleeve with Daniel’s body purported to be a suicide note written by Daniel. But, as I have outlined above, the note also provided an ostensible explanation for Gabriel’s death as well, at that time thought by the police likely to be an overdose. The question of whether the note was indeed written by Daniel was therefore absolutely critical to the investigation of both deaths. The officer tasked with ascertaining whether the handwriting was Daniel’s did not go to visit Daniel’s father in person to show him the note in its entirety. Neither did she try to prepare him for the task. Instead, as I have explained above, she emailed a scan of a one-line fragment to Daniel’s father and telephoned him a few minutes later to ask if it was his son’s. The police did not take a statement from Daniel’s father regarding the handwriting; they did not show the note to Daniel’s partner, and although they did seize a handwritten list by way of comparison, this was only one (somewhat unsatisfactory) sample, and no comparison appears to have been undertaken. 89 It was accepted by the officers concerned during the course of the evidence that the approach they took to checking whether the handwriting on the note was Daniel’s was profoundly misguided and wrong. The understanding that the police formed as a result of this misguided approach — that the handwriting was Daniel’s — had, in my view, a significant impact on the future direction that the investigation took. Therefore, although it may only very rarely be the case that the verification of a person’s handwriting might have a critical impact on future deaths, it is a matter of concern to me that this - 20 - task be carried out appropriately and sensitively to afford the police the best opportunity of any identification being accurate (MC5). 90 MC5 is addressed to the Chair of the National Police Chiefs' Council. Topics 6 and 7: Death messages and Coroners’ observations 91 Finally, I could not end this Report without mentioning two further concerns. They are not, strictly speaking, issues which give rise to a risk of future deaths, but they are matters about which I feel strongly and therefore I have decided to include them in my Report. 92 The first is that of the delivery of a death message to families / partners / next of kin. I was shocked and disappointed by the evidence that I heard, that in three of the four deaths there were errors made by those delivering the death message, and that in the fourth case (Gabriel’s) his family was not even informed by the police of his death, and thereafter the designated FLO never made contact with the family. It is obvious that the news of the death of a family member/partner is devasting. It is therefore a basic expectation of the police that they should be able to do this difficult task accurately and sensitively and I would encourage the MPS, and indeed police forces nationally, to reflect on the evidence from the Inquests on this point. 93 The second is the police investigators’ response to a Coroner’s concerns expressed during an inquest. The evidence was that the Coroner who conducted the first inquests into Gabriel’s and Daniel’s deaths (in June 2015) said that she did not have any reliable evidence upon which to come to a view as to what had led to Gabriel’s death. Regarding Daniel’s death the Coroner listed a number of misgivings that she had about the evidence she had heard from the police. Those concerns included the finding by the pathologist of bruising consistent with manual handling prior to Daniel’s death and the finding that he had aspirated some of his stomach contents. The Coroner observed that this latter finding, in circumstances where there was no vomit found at the scene — which was the place where, if the note was taken at face value, Daniel would have died — raised the question of whether Daniel’s body had been moved. And if Daniel had been moved to the graveyard, then that could be consistent with the bruising which the pathologist had found. The Coroner expressed other concerns about the police investigation, such as the fact that the police had not sent the blue bed sheet or the bottle found with Daniel’s body for forensic analysis, and that the man with whom, according to the note, Daniel had been the - 21 - night before his death had not been located. She then said in her summing up that her unease that someone could have moved Daniel to the graveyard — i.e. third-party involvement in his death — “cannot be allayed by the evidence that has been produced to the court”. She accordingly returned open verdicts for both Gabriel and Daniel. It seems to me that the Coroner’s assessment of the situation following her review of the evidence presented by the police made it manifestly clear that third party involvement in Daniel’s death had not been excluded. This should, in my view, have prompted the police to re- consider the adequacy of their investigation. I was told by DAC that the MPS intended to reflect on the best way of ensuring that any comments from a Coroner are captured, to ensure that they are considered and dealt with in an appropriate manner. I therefore invite the MPS (and indeed police forces nationally) to consider how concerns expressed by a Coroner during the course of an inquest about possible third-party involvement could, and should, be better responded to by the officers who were responsible for investigating the death. MATTER OF CONCERN: SLEEPYBOY 94 The evidence heard at the Inquests was that first made contact with Anthony Walgate through the Sleepyboy website. had used the name ‘ ’ for his Sleepyboy user profile and engaged Anthony as an escort. I was told that because Anthony had provided his friend with the details of ‘ ’, including his photograph, the police were able to establish that . Although I did not hear oral evidence from a representative of Sleepyboy, I have received two signed witness statements from the owner of Sleepyboy, dated 3rd December 2020 and 4th July 2021. I understand from those witness statements that, although there is a verification process for escorts, Sleepyboy does not require any verification from users of the site, which is free to browse and does not require any log-in. It follows from written evidence that the police would not have been able to check identity through the Sleepyboy website — because users are not asked to confirm their identities. I am concerned that this means that escorts advertising on the Sleepyboy website are left in a particularly vulnerable position. in their submissions have invited me to make a PFD report highlighting the fact that clients are able to use the Sleepyboy website to engage escorts without having to verify their identities. - 22 - 95 has explained in his second witness statement that it would “kill the business” if Sleepyboy required users to log in, as he says that “there are many other sites and you can view millions of escort profiles online without logging in”. It is beyond the scope of my investigation to examine how sustainable claim is, and, on one view, the fact that escorts on other sites are equally exposed is not an answer to my concerns about the Sleepyboy website. I am also mindful, however, of the importance of privacy to the users of Sleepyboy, and that more stringent verification of users’ identities could risk negative consequences for those users. 96 I note that the Report published on 14th December 2021 of the House of Lords and House of Commons Joint Committee on the Draft Online Safety Bill includes within it a discussion of the issues of anonymity and traceability, and that the Joint Committee has made a number of recommendations directed to (i) the risks associated with ‘disposable’ accounts being created for the purpose of undertaking illegal or harmful activity, and (ii) the establishment of minimum standards for the protections of privacy within online verification processes. It is a matter of concern that users of the Sleepyboy website can engage escorts without having to verify their identity (MC6). 97 MC6 is addressed to the Secretary of State for Digital, Culture, Media & Sport. ACTION SHOULD BE TAKEN 98 In my opinion, action should be taken to prevent future deaths. I believe that the various addressees of this Report have the power to take the action relevant to them (as set out above). YOUR RESPONSE 99 Each addressee is under a duty to respond to this Report within 56 days of the date of this Report, namely by 18 March 2022. As the Coroner responsible for the Inquests, I may extend that period upon application. 100 Each response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, it must explain why no action is proposed. COPIES AND PUBLICATION 101 I have sent copies of my Report to the following: - 23 - (a) all Interested Persons in the Inquests (identified in the attached list) (b) The Director General of the Independent Office for Police Conduct (c) The Home Secretary (d) Sleepyboy SL (e) (f) The Mayor’s Office for Policing and Crime (g) (h) Her Majesty’s Chief Inspector of Constabulary (i) The National Police LGBT+ Network; (j) The Independent LGBT+ Advisory Group to the Metropolitan Police; and (k) the Chief Coroner of England and Wales. 102 I am also under a duty to send a copy of any responses to the Chief Coroner. Addressees and others may make representations to me about the wider release or publication of any responses. HH Judge Munro QC Assistant Coroner Date: 21 January 2022 ANNEXES (a) Records of Inquest and Questionnaires. (b) List of Interested Persons in the Inquests. - 24 -
3 responses 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.
Rt Hon Nadine Dorries MP Secretary of State for Digital, Culture, Media and Sport 4th Floor 100 Parliament Street London SW1A 2BQ E: enquiries@dcms.gov.uk www.gov.uk/dcms 30 March 2022 Dear Mr Carlyon, Thank you for your email of 21 January, enclosing the coroner’s report on the tragic deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor. I would like to extend my deepest sympathies to their family and friends. The Online Safety Bill was introduced to Parliament on 17 March. It will usher in a new era of accountability for the tech sector and ensure that they take more effective action to tackle criminal activity, including when their users are anonymous. However, the regulation of tech companies is not an alternative or replacement for action by law enforcement to tackle criminals, whether they target their victims online or offline. Your report makes reference to the law enforcement's ability to undercover the identities of unverified users. The police already have a range of legal powers to identify individuals who attempt to use online anonymity to escape sanctions for criminal activity. The Investigatory Powers Act 2016 gives law enforcement powers to investigate illegal activity by requesting access to communications data. Additionally, law enforcement agencies have a power under Schedule 1 to the Police and Criminal Evidence Act 1984 (PACE) to obtain access to stored communications data held by service providers. The government is working with law enforcement to review whether the current powers are sufficient to tackle anonymous criminal activity online. While we are not familiar with the details of whether there was any illegal activity online in this case, we are, however, aware that online services do not always remove illegal content from anonymous accounts even when they are made aware of it. The Online Safety Bill places new requirements on all companies in relation to illegal content and anonymity online. Services in scope will have to ensure that illegal content is removed swiftly and that the risk of it appearing and spreading is minimised by effective systems. As part of this, services will have to identify, mitigate and effectively manage the risk of anonymous profiles. This could include, as the Joint Committee recommended and your report has highlighted, putting in place user verification methods so disposable accounts are not created for the purpose of undertaking illegal activity. Ofcom will be appointed as the new regulator overseeing the framework and will set out the types of verification methods a company could use in guidance. Ofcom will have a suite of enforcement powers available to use against companies who fail their duties. These powers include fines for companies of up to £18 million or 10% of qualifying annual global turnover, and business disruption measures. We introduced the Online Safety Bill to Parliament on 17th March 2022. We are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation. Yours sincerely, Rt Hon Nadine Dorries MP Secretary of State for Digital, Culture, Media and Sport
PROFESSIONALISM HQ
HH Judge Sarah Munro QC
HM Assistant Coroner
C/o Solicitor to the Inquests
Fieldfisher Solicitors
Riverbank House
2 Swan Lane
London EC4R 3TT
Deputy Assistant Commissioner
New Scotland Yard
Victoria Embankment
London SW1A 2JL
E-mail:
Tel:
Date:
Dear Judge
Re: East London Inquests touching the deaths of Anthony Walgate, Gabriel Kovari,
Daniel Whitworth and Jack Taylor
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the
Metropolitan Police Service (MPS). I write to respond on behalf of the Commissioner of Police
of the Metropolis in relation the concerns you have raised in the Prevention of Future Deaths
Report (‘PFD’) following the inquests touching the deaths of Mr Anthony Walgate, Mr Gabriel
Kovari, Mr Daniel Whitworth and Mr Jack Taylor which concluded on 10th December 2021.
The MPS has acknowledged and reviewed the information provided at the inquests and all
the matters of concern raised. The Coroner will be aware from letters dated 10th December
2021 and 6th January 2022 from
, solicitor for the MPS in the inquests that
matters of concern 1 – 4B were already under consideration by the MPS during the inquests.
Our response is as follows:
Topic 1: Categorisation of suspicious, non-suspicious and unexplained deaths
Matter of Concern 1:
It is a matter of concern that although the current MPS policy, the Death Investigation
Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a
sudden death should treat the scene and incident as suspicious until satisfied that it is
not, the term “unexplained” as used in the current policy may once again distract
officers from the correct and necessary approach, which is for the death to be treated
as suspicious unless and until the police investigation has established that it is not.
As a consequence of the evidence heard in court and prior to the publication of the PFD, a
working group was initiated in December 2020 to discuss the learning from the Inquest. The
working group is chaired by the MPS Homicide Commander and comprises the Commander
for Head of Profession for Investigation, detective superintendents (DSUs), duty officers and
detective inspectors from Basic Command Units (BCU), senior representatives from Forensic
Services and the MPS Murder Investigation Teams (MIT).
1
This working group has agreed four new classifications so as to provide absolute clarity to
officers responding to and investigating deaths. They are:
1. Expected death – Where there is medical diagnosis and a medical practitioner is able to
sign a Medical Certificate of Cause of Death.
2. Unexpected death - investigated and not suspicious - Where the death was sudden
and not expected. Police have attended and carried out an investigation. Evidence is
available to indicate there is no third party involvement.
3. Unexpected death - under investigation - Where the death was sudden and not
expected. Police have attended and carried out an investigation. Investigations are unable
to confirm that there was no third party involvement and further investigation is required.
4. Homicide - Where the death was sudden and not expected. Police have attended and
carried out an investigation. In all likelihood there is third party involvement or there is
obvious evidence of homicide.
Following the working group and agreement through consultation, these classification
changes will be presented to the Front Line Policing (FLP) Chief Officer Group (COG) for
approval. Once agreed, a policy change will be instigated and the MPS will embed these
changes across the whole organisation by 30th June 2022.
Topic 2: Interaction between specialist homicide investigators and BCU officers
Matter of Concern 2A:
It is a matter of concern that the current policy framework guiding decisions on primacy
still lacks clarity.
The working group referred to above has clarified that the following shall be the investigative
response for death investigations:
• Unexpected death - investigated and not suspicious - Uniformed officers shall attend
the scene and complete an investigation into the circumstances of the death. A Duty
Officer is a uniformed inspector responsible for area policing during a tour of duty. It is the
Duty Officer’s responsibility to request support from the local BCU Criminal Investigation
Department (CID), should this be required. The Duty Officer must also consider utilising
Forensic Services to recover forensic material and evidentially record the scene. The Duty
Officer is responsible for ensuring that a report for the Coroner, covering the four coronial
inquest requirements, is completed.
• Unexpected death - under investigation - When the initial investigation cannot
determine third party involvement, the CID will have the responsibility to conduct the
investigation. A Senior Investigating Officer (SIO) is to be appointed, this must be the rank
of a Detective Inspector or above. The attendance or advice of the Homicide Assessment
Team (HAT) is to be considered at this stage by the SIO. It is the responsibility of the SIO
to ensure that Forensic Services attend the scene. Forensic Services are responsible for
the retrieval, recovery and recording of forensic material, maintaining integrity and
continuity of exhibits and ensuring that they are submitted in alignment with an agreed
forensic strategy.
2
A Crime Scene Manager / Operational Forensic Manager will be able to assist in deciding
upon the cause of death along with ensuring that no forensic evidence is compromised.
The BCU Detective Chief Inspector (DCI) holds overall responsibility for the investigation
and must ensure effective action management and oversight making sure that regular
reviews are completed. The BCU DCI is also responsible for the tasking of any MIT
resources that have been provided in support of the BCU. The DCI shall report direct to
the BCU Detective Superintendent (DSU) on the review process and any outcomes. When
the threshold is met to show that in all likelihood there was third party involvement in the
death, it is for the BCU DSU, in conjunction with the Borough Forensic Manager (BFM), to
determine the rationale to be presented to the MIT. The DSU, will agree the handover and
decide on MIT/BCU resource responsibilities and the MIT will appoint an SIO. In the event
of disagreement regarding the BCU’s rationale regarding primacy it is to be escalated to
the Commander of the Homicide Command whose decision is final.
• Homicide - In the event that there is obvious evidence of homicide following BCU initial
attendance, the MIT will take primacy as soon as practicable. If following an investigation
the evidence indicates in all likelihood there was third party involvement, the MIT will
assume primacy and appoint a SIO at the earliest opportunity and within one working day.
In both circumstances, a Crime Scene Manager / Operational Forensic Manager will assist
with the decision on the cause of death along with ensuring that no forensic evidence is
compromised.
These investigative response clarifications are now to be presented to FLP COG for approval.
Once agreed, these will be incorporated in the MPS Death Investigation Policy following a
corporate governance process which will include consultation with stakeholders. It is
anticipated that publication of this policy and the implementation and embedding of these
changes across the MPS, will take place by 30th June 2022. This time is required to not only
allow for the changes required to the MPS’ Death Investigation Policy and to be reviewed by
the Frontline Policing Chief Officer Group.
Matter of Concern 2B:
It remains a matter of concern that there is a lack of clarity surrounding the levels of
support that can be expected from the specialist homicide investigators and crime
scene managers or other forensic practitioners in the investigation of deaths where
primacy remains with the BCU.
Presently there is no formal lesson plan or training provided to staff in relation to the levels of
support that they can expect to receive from specialist homicide investigators, crime scene
managers or other forensic practitioners in the investigation of deaths, which remain on BCU
for progression.
Currently informal inputs are provided on the Detective Constable (DC), Detective Sergeant
(DS) and Detective Inspector (DI) courses by the MPS Training Unit personnel as a direct
consequence of the East London Inquest touching the deaths of Anthony Walgate, Gabriel
Kovari, Daniel Whitworth and Jack Taylor. However these inputs need to be formalised.
The MPS Training Unit, Specialist Crime, Major Investigation Teams, Forensic Services and
Front Line Policing shall collectively design a formal lesson plan and present this to the
Training Design Team for inclusion in the DC, DS, DI and SIO training. This will be led and
co-ordinated by the Head of Profession for Investigation with an anticipated delivery date by
the end of June 2022.
3
Topic 3: Leadership
Matter of Concern 3A:
It is a matter of concern that despite the regularly refreshed training that is now in place
for detective sergeants and detective inspectors, and the additional leadership training
in which the MPS has invested, a lack of ownership and responsibility for the
investigations of unexplained deaths may persist in officers who are supposed to be
leading investigations into unexplained deaths.
The MIT/BCU working group has agreed and set out clear guidelines detailing the
responsibilities that officers of different ranks have in death investigations. This should leave
them in no doubt as to their responsibilities and those of their colleagues. They are as follows:
• Unexpected death - investigated and not suspicious - The attending uniformed
officers, supported by BCU DC and/or DS, have responsibility to complete an initial
investigation. It is the responsibility of the Duty Officer to ensure that a coroner’s report
is completed. The Duty Officer has overall responsibility for the investigations ensuring
actions are effectively completed and timely reviews conducted. Where appropriate,
the Duty Officer must liaise with Forensic Services who are responsible for the retrieval
and recovery of forensic material and evidentially recording the scene. The Duty Officer
is responsible for ensuring that the report to the Coroner is completed to a satisfactory
standard and is submitted in accordance with policy and local guidance.
• Unexpected death - under investigation - The BCU shall appoint a SIO which shall
be at a minimum rank of Detective Inspector. However, it is the BCU DCI that has
overall responsibility for the investigations ensuring actions are effectively completed
and timely reviews conducted. Additionally, the BCU DCI is also responsible for
responding to the HAT return and managing MIT resources should they be provided.
It is of note that all HAT returns must record the details of the appointed SIO prior to
submission and set out in detail the working hypothesis providing clarity for all.
It is the responsibility of the SIO to ensure that Forensic Services attend the scene.
Forensic Services are responsible for the retrieval, recovery and recording of forensic
material, maintaining integrity and continuity of exhibits and ensuring that they are
submitted in alignment with an agreed forensic strategy. A Crime Scene Manager or
Operational Forensic Manager (CSM / OFM) will assist in deciding upon the cause of
death as well as ensuring that no forensic evidence is compromised. Where evidence
indicates in all likelihood third party involvement, it is the BCU DSU, in liaison with the
Borough Forensic Manager that determines the rationale and presents this to the MIT
DSU. The MIT DSU is to agree the handover and decides on allocation of MIT/BCU
resource responsibilities. A MIT SIO will be appointed. In the event of a disagreement,
the Commander for Homicide has the final decision.
• Homicide - The MIT SIO is appointed as soon as practicable. A CSM/OFM will attend
the scene and assist in deciding upon the cause of death as well as ensuring that no
forensic evidence is compromised.
As previously stated in Matter of Concern 2A, these investigative oversight and governance
clarifications are now to be presented to FLP Chief Officer Group for approval. Once approved,
the policy change will be instigated and the MPS will embed these changes across the whole
organisation by 30th June 2022. Additionally directions in relation to leadership responsibility
in investigation shall be added to the DS and DI course curriculum. This shall also be achieved
by the end of June 2022.
4
Matter of Concern 3B:
A matter of concern that the SCRG, which DAC Cundy commended as an asset to assist
in the process of review of complex investigations is not, in practice, accessible and/or
properly understood as a resource.
The work of the Specialist Crime Review Group
The Specialist Crime Review Group (SCRG) is a department with highly experienced serving
officers and retired detectives who provide an independent review function for the MPS in
order to comply with legislation and policy.
The SCRG provide assistance both in person (rapid review meetings) and written responses
supporting local BCUs. Their assistance is often used for cases involving statutory reviews
including, Child Safeguarding Practice Reviews (CSPRs), Domestic Homicide Reviews
(DHRs), Safeguarding Adult Reviews
(SARs) and Multi-Agency Public Protection
Arrangement Serious Case Reviews (MAPPA SCRs).
They also provide a review function for non-statutory major crime reviews in accordance with
the Major Crime Investigation Manual (MCIM), including 28 day homicide and cold case
reviews. The SCRG also supports local investigations through the completion of critical
incident reviews as well as bespoke reviews for some complex investigations.
In addition to Non-Statutory and Statutory Reviews, the SCRG offer support to SIOs that need
advice and guidance through the provision of ‘peer meetings’. The SCRG will contact the SIO
in the case of all homicides at 7-10 days to determine if a Peer Meeting would be beneficial.
The decision taken will be documented following the SCRG Tasking Meeting. It should be
noted that a Peer Meeting is not a review of the case, it is to assist the SIO in developing lines
of enquiry.
The SCRG also have a number of ‘tactical advisors’ available who can assist and provide
advice to officers in relation to any investigation (i.e. investigations into Honour Based Abuse).
A Manual of Guidance is available to all officers regarding the work and responsibilities of the
SCRG, but may be of particular interest to SIOs, Public Protection DSUs, Review Officers
(RO), their managers and staff, and its aim is to provide guidance for the continuous review of
homicide, statutory reviews, critical incidents and other serious crime.
The SCRG capture and disseminate good practice from major enquiries and reflect learning
from corporate experience. They will ensure continuous improvement in the investigation and
management of major crime and other critical issues within the MPS.
Visibility of the work of the SCRG
The MPS internal website provides clear information to all officers and police staff in relation
to who the SCRG are, what they can do and how they can help.
Any organisational learning identified from reviews is shared quarterly with the MPS
Organisational Learning Board. Recommendations cover all aspects of policing and not just
Homicide and Public Protection. Any organisational learning or good practice is shared via a
six monthly newsletter circulated
to all MPS Homicide SIOs, Public Protection
Superintendents, and Investigation Superintendents on local BCUs for wider dissemination
amongst their teams. In addition to this, the MPS provide bi-annual training days for Homicide
SIOs and Public Protection Superintendents which relate specifically to homicides and
statutory reviews.
5
The SCRG provide a presentation on the Homicide Induction Course. This is for Detective
Constables and Detective Sergeants joining the Homicide Command to make them aware of
the work of the SCRG. They provide input on the SIO course, which is attended by Detective
Inspectors and ranks above from BCU and Specialist Crime departments, who will perform
the SIO function within the MPS.
Of note, are the comments made by Her Majesty’s Inspectorate of Constabulary and Fire and
Rescue Service (HMICFRS) following an inspection of the MPS’s response to a review of its
investigations into allegations of non-recent sexual abuse by prominent people (the ‘Henriques
report’) which was published on 13 March 2020.
HMICFRS’s view of the MPS in response to the Henriques recommendation 24 was:
“We found then that the SCRG had worked hard over the previous 12 months to promote its
services, taking part in relevant senior detective meetings, and giving inputs on courses…..
senior detectives were well aware of the SCRG. It was also pleasing to find a good level of
awareness at BCU sergeant and inspector levels.”
Between January 2013 and January 2022, the SCRG has supported the work of BCUs by
conducting statutory and non-statutory reviews into the following areas:
Statutory reviews
• 198 Domestic Homicide reviews (DHRs)
• 72 Safeguarding adult reviews (SARs)
• 210 Serious Case Reviews (now Child Safeguarding Practice reviews - CSPR)
• 87 ‘rapid reviews’ (conducted prior to formal adoption of a CSPR)
• Since 2016 we have conducted 11 Multi-Agency Public Protection Arrangement
(MAPPA) Serious Case Reviews (MAPPA SCRs)
Non-statutory reviews
• 60 Critical Incident reviews.
• Since 2016 we have conducted 260 missing person reviews after a missing person
has be found deceased.
• Since 2020 we have conducted 101 Homicides within a Domestic Setting reviews in
response to concerns regarding domestic abuse during the pandemic.
Moving forward, in order to continue raising awareness of the SCRG and what they can do to
support BCU officers, they will also:
1. Give presentations annually regarding the work of the SCRG to both Public Protection
and Investigation Superintendents at one of their monthly meetings chaired by the
respective heads of profession.
2. Members of the SCRG will ask to attend Senior Leadership Team (SLT) meetings on
each of the 12 BCUs and give presentations to the respective SLTs in relation to who
the SCRG are and what they can do to support the work of the BCUs.
3. Look to share its newsletter with all Professionalising Investigation Programme 3
(PIP3) SIOs, not just those working on Homicide or BCU Public Protection and
Investigation Superintendents.
4. Develop an open SharePoint channel where information regarding the work of the
SCRG can be updated and shared across the MPS.
6
It is envisaged that the SCRG will attend the Superintendent meetings, share its newsletter
with all SIOs, and develop its SharePoint channel within the next three months, and attend all
SLTs within the next six months (dependent on the BCU availability).
In conclusion, whilst the SCRG are known widely to both homicide SIOs and Public Protection
Superintendents, with this further activity the work of the SCRG will become more widely
known across the MPS.
Topic 4: Use of the CRIS / new CONNECT system
Matter of Concern 4A:
A matter of concern that whatever the system, CRIS or CONNECT, officers may not
record lines of investigation, actions and outcomes, and
Matter of Concern 4B:
A matter of concern is that the CRIS was closed by supervising officers without any
review of whether the actions had been completed or any critical assessment at
detective sergeant level or detective inspector level of whether the investigation had
established that the death was non-suspicious.
The existing MPS Crime Report Information System (CRIS) has functionality that allows
supervisors to issue key actions and track progress against an investigation. Already used
extensively within criminal investigations, it will need to extend to Crime Related Incidents
(CRI), also recorded on CRIS, used as a means of recording unexpected death investigations,
and will allow key inquiries and forensic submissions to be tracked and progress reviewed.
As part of a forthcoming revision of the existing MPS Death Investigation Policy, stricter
guidance will be introduced which will mandate tighter governance around those investigations
classed as ‘unexpected death – under investigation’. The Head of Profession for Investigation
will ensure that this includes the following:
• Cascade policy changes throughout Front Line Policing.
• Reiterate the requirement for the investigative strategy to be clearly set out.
• Focus on supervision and forensic manager guidance and oversight.
•
• Use of crime investigation action tracking.
• Embedding local (BCU) governance to track progress at both tactical and strategic
Importance of recording follow-up actions to HAT advice.
level, providing confidence in case progression or closure.
Initial dip sampling to share good practice and highlight areas for improvement.
•
• A lesson will be added to the DS and DI course curriculum emphasising the importance
of reviewing and signing of actions as complete. This shall be achieved by the end of
June 2022.
These approaches will take account of the future Connect IT system changes anticipated to
take place in 2023.
In response to the Coroner’s observations of concern which are not subject of the Paragraph
28 Report on Action to Prevent Future Deaths, the MPS provides the following response:
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Topics 6: Death messages and Coroners’ observations
The delivery of a death message is undoubtedly one of the most difficult tasks that a police
officer is asked to do and is the most devastating news that a family will receive. It is therefore
vitally important that police officers are able to do this difficult task with sensitivity and have
received guidance in how best to prepare.
Training
All new police officer recruits receive two sessions in relation to sudden death and delivery of
a death message. These sessions fall under the Policing Education Qualification Framework:
a. Dealing with a sudden Death – session number PU0054.
b. Bereavement Messages – session number PU0140.
All officers who attend a Family Liaison Officer (FLO) course receive a lesson on delivery of a
death message. The lesson lasts approximately one hour and takes the learner through a
series of steps, culminating in a role play of delivery of the death message.
In the MPS, eligibility to attend a FLO course comes with detective status, or working on the
Road Transport Policing Command, subsequently limiting the number of officers who can
receive this training. It is worthy of note that there are 735 FLOs in the MPS across all areas
of policing.
Guidance on the MPS Internal Website
Apart from the training mentioned above which pertains to all sudden deaths, there is
additional guidance on the MPS intranet which is contained within the MPS Death
Investigation Policy. The guidance is specific to the MPS COVID response and contains
advice for the delivery of death messages.
The MPS has produced a leaflet entitled ‘Bereavement Information’ which provides
information surrounding roles and responsibilities and support agencies following notification
of a death. This leaflet is to be left with bereaved families and provides them with details of
the officer delivering the death message. The leaflet is easily accessed on the MPS intranet.
The MPS Family Liaison Policy and MPS Death Investigation Policy signpost officers to the
Death Notification Advice line which is a resource for MPS officers and Army personnel who
are delivering the death message and require advice.
Additional Steps
Following a review of this area, the steps set out below shall be undertaken to enhance access
to literature, understanding of the complexities of delivering a death message and achieve
consistency of learning:
• Ensuring that the learning delivered within the FLO course incorporates College of
Policing approved training packages, ‘Dealing with a Sudden Death – session number
PU0054’ and ‘Bereavement Messages – session number PU0140’.
• Enhancing the guidance and advice on the delivery of death messages found within
the MPS Death Investigation Policy making it applicable to all deaths.
• Publication MPS wide of the existence of the Death Notification Advice Line telephone
number.
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The implementation of the above progressive steps will be co-ordinated by the Family Liaison
and Disaster Management Team with an anticipated delivery date in August 2022.
Topic 7:
In the 2015 inquests, the previous Coroner recorded open verdicts and did not rule out
third party involvement. Despite this, there was no further investigation by the officers.
Presently there is no formal process for a coroner to raise concerns about an investigation. It
is currently an informal process depending on the coroner being aware of who is acting as the
investigating officer before the inquest, which is not always the case.
The MPS Directorate of Professional Standards (DPS), Specialist Crime, Major Investigation
Teams and Front Line Policing will collaborate to provide a formal process for the Coroner to
raise concerns about an investigation and how these will be actioned. The Directorate of
Professional Standards Inquest Team will implement a standard process for coordinating the
response to any concerns or actions required by the Coroner during or at the conclusion of an
Inquest. This will be incorporated within the Death Investigation Policy and communicated to
all investigators by the end of June 2022.
Areas of learning identified by the MPS
In addition to the above matters of concern and observations raised within the Paragraph 28
Report on Action to Prevent Future Deaths, the MPS identified a number of areas of learning
were identified during the inquests and took immediate action to address them. They are
detailed below.
Commander CPIE to carry out a review on the effectiveness of the practice of
engagement by LGBT+ advisors across a number of types of cases pan-London.
letter of 10th December 2021 mentioned the review of the role of LGBT+ Advisors.
The MPS recognises the need for this as a result of both the East London Inquests and the
IOPC investigation into how the MPS investigated these tragic murders. We have also listened
to our LGBT+ Independent Advisory Group (and feedback from other community members)
who are keen to help the MPS consider how this role could evolve to provide a better service.
The MPS has outlined our approach to the IOPC which includes broad consultation to
understand the needs and expectations of London’s LGBT+ communities. There are a number
of elements that will need to be explored including responsibilities for community engagement,
support for victims, provision of advice to MPS colleagues (e.g. investigators, leaders and
neighbourhood policing), reviewing processes and how this is resourced, supervised and
performance managed. This will ensure we have an agreed, consistent LGBT+ Advisor model
across London.
We have already informed our existing LGBT+ Advisors that this review is happening and
have consulted our internal LGBT+ Network (staff support association) who support this
approach. Governance will be provided through the LGBT+ Organisational Improvement
Working Group which agreed this project commences at its most recent meeting in February
2022.
Provision of information on how MetInsights work for the Coroner
Our response to this learning was provided in
For ease of reference our response was:
letter dated 10th December 2021.
9
6.
7.
8.
9.
Data analytics tool called MetInsights has been developed that can bring together
information from a number of different systems and enable local intelligence teams to
identify potential links and crossovers (19 Nov, pp. 154/23-155/7).
MetInsights can extract and present information from the CRIS, MERLIN and EMWS
platforms. It assists in processing, manipulating and presenting data in a quick and
user-friendly manner. Data can be obtained showing crimes in certain categories or
areas.
For example, a user can request data on a particular crime type in a given area, or
produce a map showing all reported unexplained deaths in a given area. Once the
personal data function is enabled (this element has been approved and is in process
of being implemented), further filtering will be possible, for example, filtering for age.
Hotspots, repeat venues or certain trends should be easily identifiable, prompting the
user to investigate further.
The Pinboard function enables searches to be brought together, creating dashboards
which can reveal trends and risks, enabling a user to identify issues which they may
not have otherwise seen. Being able to map and interrogate three datasets adds
significant value to the MPS’ ability to identify patterns in offending and potential links
between investigations.
10. MetInsights is in operational use. Training sessions are provided to users along with
online training tools for self-learning. There are currently approximately 7,000
registered users and 500-600 active users per month.
Urgent review of the Detective Sergeant and Detective Inspector training on the role
and expectation at a Special Post Mortem – briefing to pathologist and recording and
understanding immediate findings and considerations.
Detective Sergeants and Detective Inspectors’ training on the role and expectation at a Special
Post Mortem, which encompasses briefing a pathologist and recording and understanding
immediate findings and considerations, has been designed and added to the Detective
Sergeants and Senior Investigating Officers’ course syllabus. The course commenced in
January 2022.
Review of Death Investigation Policy and associated guidance on police attendance at
Coronial Inquest, role and responsibilities of officer in attendance and expectations on
the capture of any comments/findings by the Coroner and police response and
subsequent action.
The MPS Death Investigation policy is being amended to direct that all recommendations
made by a pathologist during a post-mortem/verbal debrief are documented, fed back to the
investigating officers and recorded on the investigation record. The policy will also be
amended to direct that an Investigating Officer must record within a Decision Log and/ or CRIS
report the rationale for not following a pathologist’s recommendation.
Additionally, definitions of death investigations are being re-written to simplify and embed a
structured investigative approach and detail the appropriate responses required by front line
officers to each classification. The actions required by supervisors will also be defined. The
Death Investigation Policy will be amended to inform officers once the definitions are defined.
The policy will include a direction to utilise ADR screens of the investigation report to document
and manage Actions, Decisions and Reviews.
10
Officers from Specialist Crime attend all suspicious death Special Post Mortems (SPM),
together with colleagues from Basic Command Unit Criminal Investigation Departments (CID).
A Crime Scene Manager will also attend, together with a photographer.
A briefing will be provided to the pathologist of the circumstances known of the death, together
with any relevant exhibits, for example, weapons suspected to have been used and
photographs. At the conclusion of the SPM a debrief is held between all parties so that the
pathologist can provide an update on the cause of death, any specific issues and direct further
work be conducted, for example, examination of specific body parts/organs and toxicology.
Where the cause of death is established to be non-suspicious or unexplained pending further
analysis e.g. histology/ bloods, and primacy of investigation remains with the BCU, the
Specialist Crime officers will provide the BCU’s CID investigators with an updated HAT report
describing actions required to progress the investigation.
The CID officers would be expected to transpose the action plan onto the CRIS report either
within the body of the details of the investigation screen (“DETS”) or best practice would be to
utilise the Action, Decision and Review screens (“ADR”).
In the case of a standard post mortem, any commentary of the pathologist would be
communicated via the Coroner’s Officer to a BCU’s investigating officer. This may include a
decision by the Coroner that a SPM is now required to satisfy the need to give a cause of
death and identify any suspicious circumstances. At this point that advice must be sought from
Special Crime Major Investigation Team officers, who would attend as above.
Again, the CID officers are expected to transpose any comments or recommendations from
the pathologist during the standard Post Mortem onto the CRIS report. This would be within
the body of the DETS screen or best practice would be to utilise the Action, Decision and
Review screens (ADR).
The CRIS system requires that the ADR screens are reviewed by a supervising officer so
adequate management of investigations is imposed recognising the serious nature of death
investigation and ensuring the correct rationale is used when not completing an action or
prioritising the completion of actions due to resourcing constraints. A supervising officer should
review all investigations to ensure valid decisions are made and professional curiosity is
exercised to explore all lines of enquiry.
Any decision not to follow the recommendations of the pathologist should be recorded on the
CRIS investigation report with a rationale.
These changes to policy will be communicated via PIP2, PIP3 and PIP3 (Professionalism
Investigation Programme) Continued Professional Development inputs and via the MPS
internal website.
It is proposed a new “N” code will be introduced to classify death investigations on the CRIS
system which are not classified as murder but require further investigation to clarify the
circumstances. This will allow for analysis of cases under investigation and support the
investigation and supervision protocol described above. Introduction of the “N” code CRIS
classification will be subject to a national paper submitted to the NPCC Homicide Lead.
Forensic guidance is provided as a training input to all investigator training courses for PIP2,
PIP3 and PIP4 accredited officers. This includes an input on SPM attendance, the briefing of
pathologist, the SPM procedure, debrief and actions post SPM. The courses are led by an
11
experienced SIO and there is an input on HAT returns and the expectation on supervisors to
record and act on advice.
The amended Death Investigation Policy will be published in three months (by 30th April 2022)
via the MPS intranet. This work is being undertaken by MPS Continuous Improvement Team
on behalf of NPCC Professional Lead for Investigations.
There is no current formal process for a coroner to raise concerns about an investigation. It is
currently an informal process depending on the coroner being aware of who is acting as the
investigating officer before the inquest, which is not always the case.
As stated in our response to point 2 of your PFD report, the MPS Directorate of Professional
Standards (DPS), Specialist Crime, Major Investigation Teams and Front Line Policing will
collaborate to provide a formal process for the Coroner to raise concerns about an
investigation and how these will be actioned. The Directorate of Professional Standards
Inquest Team will implement a standard process for coordinating the response to any
concerns or actions required by the Coroner during or at the conclusion of an Inquest. This
will be incorporated within the Death Investigation Policy and communicated to all
investigators by the end of June 2022.
Review of the wording in the Death Investigation Policy sections in relation to Family
Liaison and the wording used, and
Review of FLO and Death Investigation Policy and the use of the term ‘next of kin’ for
family contact.
The MPS Death Investigation Policy has been reviewed and the phrase “traditional” has now
been removed with the wording now consistent with the College of Policing’s Investigation
Authorised Professional Practice (Chapter 7). It now reads: “in this context, the word ‘family’
includes partners, parents, siblings, children, guardians and others who may not be related
but who have a direct and close relationship with the victim.”
On 18th December 2021, the MPS Death Investigation Policy was amended under “Contact
with family of the deceased / Next of Kin (NoK”) to include contact with family and/or next of
kin, and has adopted the definition of family as stated in the College of Policing’s Investigation
Authorised Professional Practice (Chapter 7). The definition of family now includes partners
and “others who may not be related, but have a direct and close relationship with the victim”.
Reference is already made to the College of Policing’s Investigation APP in the Family Liaison
Policy where family is defined as above.
Review of the practice guidance and oversight of completing and signing-off action in
Connect Investigation
The response we provided in
For reference our response was:
letter dated 10th December addresses this learning.
12. DAC
said that the MPS will look at what the CRIS system can do to prevent an
officer entering something that is inaccurate such as an action being completed when it has
not been (19 Nov, pp.223/14-224/5).
a. On the CRIS, the Action, Review and Decision pages facilitate the recording of
actions for an investigator. The result is written on the system and marked as
complete to draw it to the attention of the supervisor. Once notified, the supervisor
can tick a box to confirm the action is complete.
12
b. The CONNECT Investigation platform is replacing CRIS. When it goes live, all new
investigations will be recorded and investigated on CONNECT. Outstanding
actions on a CONNECT investigation are clearly visible, so when an investigation
is going through the two-stage closure process (OIC’s Supervisor & Crime
Management Services) it will be clear to the user that an action has or has not been
completed. Where an action is marked as complete, it needs a supervisor to
review, agree and show the action as complete. The CONNECT Action Plan
functionality therefore assists in mitigating the risk of closing an investigation when
actions are still outstanding. As with CRIS, it does not – and cannot – prevent a
supervisor marking an action as complete when this is inaccurate. The supporting
CONNECT Policy will provide clear direction and reinforce the roles and
responsibilities of supervisors regarding reviewing and showing actions as
completed.
Conclusion
I wish to express my sincere condolences to each of the families of Anthony Walgate, Gabriel
Kovari, Daniel Whitworth and Jack Taylor. The MPS is committed to promoting a culture of
learning and continuous improvement wherever possible.
I trust this provides the reassurance that the MPS has considered the matters of concern and
observations you have raised. Please do not hesitate in contacting me should you have any
queries.
Yours sincerely
Deputy Assistant Commissioner
PP Cmdr.
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HHJ Sarah Munro QC, c/o Solicitor to the Inquests Fieldfisher Riverbank House, 2 Swan Lane, London EC4R 3TT 18th March 2022 Re: Inquests touching the deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor. Response to Regulation 28 report on action to prevent future deaths Dear HHJ Munro, We write on behalf of the National Police Chiefs Council (NPCC) and the College of Policing in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and the prevention of future deaths reports sent to the Metropolitan Police Service, the NPCC and the College of Policing, dated 21 January 2022. The NPCC brings police forces in the UK together to help policing coordinate operations, reform, improve and provide value for money. It has the following functions: • The co-ordination of national operations including defining, monitoring and testing force contributions to the Strategic Policing Requirement, and working with the National Crime Agency where appropriate. • The command of counter terrorism operations and delivery of counter terrorist policing through the national network as set out in the Counter Terrorism Collaboration Agreement. • The co-ordination of the national police response to national emergencies and the co-ordination of the mobilisation of resources across force borders and internationally. • The national operational implementation of standards and policy as set by the College of Policing and Government. • To work with the College of Policing, to develop joint national approaches on criminal justice, value for money, service transformation, information management, performance management and technology. • Where appropriate, to work with the College of Policing in order to develop joint national approaches to staff and human resource issues, including misconduct and discipline, in line with the Chief Officers’ responsibilities as employers. The College of Policing is a professional body for everyone working across policing and • Connects everyone working in the police and law enforcement to understand their challenges. • Uses evidence-based knowledge. • Helps police officers and staff; researchers, academics and learning providers; the international policing community; and the public. • Gives a voice to professional policing on standards, skills and capabilities. Whilst the College of Policing and the NPCC have separate and distinct responsibilities, the two organisations frequently work together on national approaches to policing guidance. As such, this response is provided jointly in respect of both organisations’ separate prevention of future deaths reports. Your notice sets out the concerns that arose from the inquests touching the deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor. We are deeply sorry that there were police failings in the initial investigations into the murders and that the police response did not meet the required standards or expectations of the victims’ families. We extend our heartfelt sympathies to the families and friends of those who were murdered and we share your commitment to address the issues that have been identified. Page 2 of 11 You specifically asked for a response from the NPCC and College of Policing in relation to five matters of concern. In formulating this response there has been close cooperation with the Metropolitan Police Service to better understand the full circumstances and where possible ensure the alignment of any changes required in policing guidance or practice. We are aware you heard evidence at the inquests from Deputy Assistant Commissioner on behalf of the Metropolitan Police Service, who is also the NPCC professional lead for homicide investigations. At the inquests he provided evidence on a number of substantial changes to national police guidance and training that had already taken place since the terrible murders of the four young men in 2014 and 2015. In April 2017, the NPCC Homicide Working Group commissioned a revision of the Murder Investigation Manual (2006) and Major Investigation Room Standardised Administrative Procedures (2005). The revision of these two important guidance documents was undertaken in conjunction with the College of Policing and involved experienced senior investigating officers and police practitioners who were supported by a number of experts and professionals. In 2021, following extensive consultation and revisions, including learning from the investigations into the murders committed by , the NPCC published the new Major Crime Investigation Manual and Major Investigation Room Standardised Administrative Procedures. These national publications provide a strong and critical foundation for homicide and major crime investigations and are a key component of the professionalisation of investigative practice within policing. The College of Policing Authorised Professional Practice (APP) for Major Investigations contains links to both sets of guidance, which are also available through the National Police Library. The guidance reflects the considerable developments in homicide and major crime investigations, including: • Major investigations and the role of the Senior Investigating Officer – accreditation of Senior Investigating Officers, the role of the PIP Level 4 strategic investigator and the categorisation of homicide investigations, which reflects the complexity and resourcing requirements of investigations. Page 3 of 11 • The strategic management of major crime investigations – the importance of adopting a professionally curious mind-set, testing investigative hypotheses and the use of the National Decision Model in investigative decision making. • Linked series investigations, and • Reviews of major crime investigations – progress reviews, unsolved case reviews and post judicial reviews. Our response to the five specific matters of concern set out in your notice are detailed below. Chief Constables have already been informed of the inquests outcomes and will be updated on the wider policing response to the matters of concern you have raised. Matter of Concern (MC1): “It is a matter of concern that although the current MPS policy, the Death Investigation Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a sudden death should treat the scene and incident as suspicious until satisfied that it is not, the term “unexplained” as used in the current policy may once again distract officers from the correct and necessary approach, which is for the death to be treated as suspicious unless and until the police investigation has established that it is not.” The College of Policing delivers the Policing Education Qualifications Framework (PEQF) curriculum. It is also publishes Authorised Professional Practice (APP) as the official source of professional practice for policing. Police officers and staff are expected to have high regard to APP in discharging their responsibilities. There may, however, be circumstances when it is perfectly legitimate to deviate from APP, provided there is clear rationale to do so. With respect to homicide the relevant section within APP is titled “Major Investigation and public protection.” In close consultation with the Metropolitan Police Service, the NPCC and the College of Policing are in the process of finalising a new classification for death investigations (to be completed by Summer 2022. The revised classifications will be: 1. Expected death. For example, where there is medical diagnosis and a medical practitioner is able to sign a medical certificate of cause of death. Page 4 of 11 2. Unexpected death – under investigation. Where the death was not expected and the police investigation has not yet been able to prove or disprove there was no third party involvement and further investigation is required. 3. Unexpected death – investigated and not suspicious. Where the death was not expected and the police investigation has secured evidence to indicate there is no third party involvement. 4. Homicide - Where the death was not expected and the police investigation has established in all likelihood there was third party involvement, or obvious evidence of homicide. These new classifications are intended to ensure that there is clarity around the correct and necessary approach to death investigation; namely all unexpected deaths should be investigated and treated as suspicious until the police investigation has established it is not suspicious. This approach is intended to remove ambiguity that may lead to differing responses to death investigations. The NPCC are also working with the Home Office to develop a new consistent approach to recording homicide and death investigations across police forces in England and Wales, which is hoped will continue to build public confidence in police death investigations. This project includes a review of the current Home Office Counting Rules to identify any changes that may be required in how deaths are recorded by police. The above classifications for death investigations will be cross-referenced to any new definitions within the Home Office Counting Rules. The College of Policing and NPCC have undertaken a joint review of the policing curriculum and national policing publications that inform death investigations for use of the term “unexplained deaths”. In some publications it was identified the term had been used interchangeably with the term “unexpected deaths”. References to “unexplained” in the policing curriculum, or publications, are in the process of being removed and replaced with the word ‘unexpected’. This work will be largely concluded by the end of March 2022. For clarity, references to “unexplained” were found in the following publications: • College of Policing (2019) Practice advice: The medical investigation of suspected homicide • College of Policing (2019) Practice advice: Dealing with sudden unexpected death Page 5 of 11 • Investigation APP Unexpected deaths • PIP2 Investigative Supervisor/Manager Programme National Policing Curriculum • Policing Education Qualifications Framework curriculum (PEQF) The following documents are currently subject to wider review and updated versions are likely to be published in Summer 2022: • A Guide to Investigating Child Deaths • Guidelines on dealing with cases of encouraging or assisting suicide Matter of Concern MC2A ‘In the context of these unexplained deaths, which were extremely challenging to investigate, SC&O1 — the specialist homicide investigators — were reluctant to take primacy. It is a matter of concern that the current policy framework guiding decisions on primacy still lacks clarity.’ Police forces across England and Wales have a number of different arrangements in terms of which units investigate homicides and other death investigations. In many police forces there are dedicated homicide and major crime investigation teams, in others this function is provided under cross-force collaborative arrangements, in some forces homicides are investigated by teams that are established by co-opting investigators from different policing units. Regardless of how such investigations are resourced and led, it is important that there are clear decision making criteria as to which investigation units take primacy for particular death investigations. The learning from the inquests is being used to update national policing guidance and will be shared with forces so that they can review, and where required, update their own force policies for death investigation. The NPCC national lead for homicide investigation will be writing to all Chief Constables, detailing this specific aspect of learning from the investigations into the murders committed by . This will include a request for all Chief Constables to review their force policies and procedures and assure themselves that they have clear decision making processes, which are understood, when deciding which units should investigate different death investigations. This request will be supported by the College of Policing who will be Page 6 of 11 updating APP to state that chief officers are required to consider how unexpected deaths are allocated for investigation, and that forces should have suitable policies in place to guide such decision making. Once the new guidance on the classification of death investigations (as set out in response to MC1) has been finalised, all relevant national guidance and publications will be updated. The College of Policing is also in the process of reviewing the “Investigative supervisor / manager programme” to ensure there is clear reference to unexpected deaths and decision making processes for the allocation of investigations. It is expected this review will conclude by April 2022. Matter of Concern MC2B ‘It remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU’ The arrangements for the provision of specialist support from homicide investigators and forensic or other professionals, depending on policing arrangements, can be different between forces for the reasons as described above (see response to MC2A). In their letter to Chief Constables, the NPCC national lead for homicide investigation will be requesting they undertake the appropriate action to ensure national guidance is shared and understood within their police force and to assure themselves that the policies followed in the force or collaborative arrangements, provide the appropriate clarity and specialist support for investigators. The College of Policing will be updating the “Investigative supervisor / manager programme” to ensure that appropriate sources of expert advice are included; for example access to accredited Senior Investigating Officers or Crime Scene Investigators. References to the levels of support available will be included in APP for Investigation. NPCC and the College of Policing are also making revisions to the Major Crime Investigation Manual to ensure there is clear guidance that Senior Investigating Officers Page 7 of 11 understand the importance of providing the required support to unexpected death investigations, particularly where unexpected deaths may not appear as suspicious. These developments are intended to be completed by the end of April 2022. Matter of Concern MC3A ‘It is a matter of concern that despite the regularly refreshed training that is now in place for detective sergeants and detective inspectors, and the additional leadership training in which the MPS has invested, a lack of ownership and responsibility for the investigations of unexplained deaths may persist in officers who are supposed to be leading investigations into unexplained deaths’ The College of Policing will be reviewing and making any required changes to the national curriculum, the “Investigative supervisor / manager programme” and APP, to ensure there is clear guidance on the responsibilities of those leading death investigations. In their letter to Chief Constables, the NPCC national lead for homicide investigation will be requesting forces undertake the appropriate action to ensure that force or collaborative arrangements have the required policies and processes to assure themselves that those leading death investigations understand their responsibilities. The College of Policing will include the responsibilities for those supervising or leading death investigations within the revised death investigation guidance. These developments are intended to be completed by the end of April 2022. Matter of Concern MC3B ‘It nevertheless remains a matter of concern that the SCRG, which DAC commended as an asset to assist in the process of review of complex investigations is not, in practice, accessible and/or properly understood as a resource’ Page 8 of 11 All police forces in England and Wales are required to provide the relevant information for statutory reviews, which include Child Safeguarding Practice Reviews, Domestic Homicide Reviews, Safeguarding Adult Reviews and Multi-Agency Public Protection Arrangement Serious Case Reviews. Dependent on local arrangements, review units may also provide a review function for non-statutory major crime reviews in accordance with the Major Crime Investigation Manual, critical incident reviews and other bespoke reviews. The arrangements to undertake reviews of criminal investigation can be different across police force within England and Wales. Many forces have dedicated review teams, established by the force or via regional collaborations; other forces use investigation units to conduct reviews as part of wider unit responsibilities. The fundamental objective of any review is to constructively evaluate the conduct of an investigation to ensure; • • • • • it conforms to nationally approved standards; it is thorough; it has been conducted with integrity and objectivity; that no investigative opportunities have been overlooked; and that good practice is identified. The NPCC and the College of Policing have been working together to develop a national role profile for a Review Officer, which details their key duties, responsibilities and functions. The policing curriculum has also been updated to include the functions of a Review Officer. The College of Policing will be delivering a new nationally accredited review officer course this year. A National APP for reviews has been jointly developed by NPCC/CoP and is due to be published by Summer 2022. This new APP will provide guidance for the delivery of the general review processes, which is transferable across different types of reviews and should be considered alongside specific guidance for major crime and statutory reviews. Page 9 of 11 The importance of raising the profile and awareness of review units and their capabilities will continue to be raised through the national network of review officers and by the NPCC lead for homicide investigation and reviews. Matter of Concern MC5 ‘Therefore, although it may only very rarely be the case that the verification of a person’s handwriting might have a critical impact on future deaths, it is a matter of concern to me that this task be carried out appropriately and sensitively to afford the police the best opportunity of any identification being accurate’. The NPCC and College of Policing guidance and training states that investigative decisions should be recorded. This would include a line of enquiry to establish who has, or may have, written a note, letter or other document. How such enquiries are undertaken should be in accordance with the Senior Investigating Officer’s strategy. In accordance with existing guidance, handwriting analysis should be undertaken by a professional, who is able to provide expert evidence for the purpose of the investigation. In such circumstances it is expected that family members and / or close friends would be asked to provide the police with samples of the deceased’s handwriting for comparative analysis. In some situations, the Senior Investigating Officer may decide to seek views from a family member or associate as to the content or authorship of a note, letter or other document. This should be undertaken sensitively and as with the securing of other evidence, where evidence is provided it should be properly recorded, usually in a signed witness statement. The practice and delivery of forensic science in England and Wales is governed by the quality and standards as set out by the Forensic Regulator in their ‘Codes of Practice and Conduct For Forensic Science Providers and Practitioners in the Criminal Justice System’, which applies to all forensic science practitioners providing services to the criminal justice system. Forensic handwriting analysis is one strand in the forensic science of Questioned Document examination (QDE). Forensic expertise in QDE is predominantly provided by commercial or Page 10 of 11 independent forensic providers, rather than in-house police forensic units. These services are accessed by police forces through their local forensic contractual arrangements. Awareness of handwriting comparison as a forensic discipline and access to expertise is managed through police forensic management and submission teams. Whilst not a frequently used forensic discipline, it is a widely recognised capability within the forensic community. Good practice awareness on forensic submissions, including handwriting comparison, is available through the ‘Forensic Submissions Good Practice Guide’ (published by the NPIA, now superseded by the College of Policing). This guidance was published in 2012 and a review has been initiated between the College of Policing and the police Forensic Capability Network. We hope this response addresses the matters of concern you raised. Should you have any further questions in relation to our response, please send them to: Yours sincerely, Chair Chief Constable CEO National Police Chiefs’ Council College of Policing Page 11 of 11
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