Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0235, written 29 Jul 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2022 |
|---|---|
| Reference | 2022-0235 |
| Deceased | Christopher Boughton |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Christopher Dominic BOUGHTON
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
•
, Chair of the National Police Chiefs’ Council,
National Police Coordination Centre, 2nd Floor, 10 Victoria Street,
London SW1H 0NN –
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Christopher Dominic Boughton was
opened on 16th December 2021. It was resumed and evidence was heard
on 7th and 8th July 2022, when it was concluded.
I found the medical cause of death to be:
1a. Suspension
I determined that Mr Boughton took his own life by hanging in a wooded
location in Oxshott, Surrey, at some point between being dropped off in
the vicinity by a taxi on the morning of 3rd November 2021 and when he
was found deceased by friends searching for him on the morning of 5th
November 2021. He was reported missing to Police by his Partner and
subsequently by his Father just after midnight on 4th November 2021. He
was found by friends searching known areas that he liked to visit in the
vicinity of where his mobile phone indicated he was located.
4 CIRCUMSTANCES OF THE DEATH
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On the morning of 3rd November 2021, Mr Boughton left his home in Lambeth,
seemingly to attend his office in London for work. He had told his partner the
previous day that he felt he was having a breakdown and that he had no way
out of this situation. He did not arrive at work and was reported missing by his
Partner and then his Father just after midnight on 4th November 2021. The
investigation was assigned to the Metropolitan Police Service (“MPS”).
On the evening of 4th November 2021, phone cell site data showed Mr
Boughton’s mobile phone to be in the Leatherhead area. An email was sent by
MPS to Surrey Police (“SP”) using non-urgent email addresses, attaching a map
showing an area measuring 3,126 metres in Leatherhead, Surrey, and MPS
tasked SP to “send a unit to search the area”. SP deployed a unit to check car
parks and train stations in the area but without success.
At 04.52am, MPS were able to ascertain from financial enquiries into Mr
Boughton’s accounts and resulting enquiries with Uber that Mr Boughton had
been dropped off by taxi at Fairoak Lane at the Junction with The Avenue in
Oxshott on the morning of 3rd November 2021. Again, this information was sent
by MPS to SP via non-urgent email addresses, but was responded to within 10
minutes, with SP iCAD being re-opened and updated at 5.06am with the
location where Mr Boughton had been dropped off and a request to check this
area.
MPS indicated they considered the investigation should now be transferred to
SP, but SP awaited the written transfer form from MPS. Family and friends of
Mr Boughton organised a search of the area, with knowledge of his known
favourite locations, and he was found, obviously deceased, at 8am, prior to SP
undertaking a further search.
5 CORONER’S CONCERNS
The evidence of Detective Inspector
, Tactical and
Policy Lead for MPS, highlighted a concern that in tasking and
transferring investigations between bordering Police forces, there is a lack
of ownership and discussion between officers at Inspector level or above
between forces, which would ensure effective tasking and, when
necessary, smooth transfer of investigations. Requests were made by
email and CAD, without discussions between officers.
This was confirmed in the evidence of Detective Chief Constable
of SP, who stated that from her perspective there was a lack of
feedback from SP to manage MPS’ expectations regarding a search for Mr
Boughton.
In respect of the initial search, this meant that SP did not advise MPS that
they considered the search request unfeasible given the extent of land
outlined and the limitations on searching wooded areas during winter
night hours.
In respect of the request for a further search with more precise location
detailed provided, MPS did not disclose all of the information available
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regarding Family and friends potentially being able to assist in finding
the location based upon where Mr Boughton used to visit. There was no
feedback from SP regarding when a search might take place, leading MPS
to consider deploying its own search team.
Whilst contact telephone numbers for Officers at MPS and SP were
provided on the CAD, there is no evidence that direct contact was made
between the forces to discuss the investigation and how best to move this
forward. A SP officer recorded on the CAD that until the transfer
document was received from MPS, SP were unable to arrange a search or
contact the specialist search team.
Whilst DI
gave evidence that he is aware the NPCC is
reviewing issuing guidance around tasking and transfers between
bordering Police forces, at present there appears to be no requirement for
appropriate Police Officers to make telephone contact between forces to
ensure effective tasking and transferring, in addition to the required
written requests. This means an opportunity to discuss and pass on all
relevant information between forces may be lost.
The MATTERS OF CONCERN are:
1. The lack of any detailed requirement for telephone discussion
between appropriate police officers on sending through written
tasking requests and considering transfers of investigation means
that an opportunity to discuss and ensure smooth transition and
passing on of relevant information is lost. This may cause delay in
effective action being taken by the tasked Force, or (in the case of
transfers) by the Force to whom it is considered a transfer will be
made.
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
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Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See paragraph 1 above
2.
3.
4.
5. The Chief Coroner
, Legal Department, Metropolitan Police Service
, Weightmans LLP for Surrey Police
In addition to this report, I am under a duty to send the Chief Coroner a
copy of your response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who,
he believes, may find it useful or of interest. You may make
representations to me at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 29th day of July 2022
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1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Anna Loxton
HM Assistant Coroner for Surrey
Hon Secretary Coroners’ Society of England & Wales
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
By email only:
Date: 22nd September 2022
Dear Ms Loxton,
Regulation 28 Report – Mr Christopher Dominic Boughton
I write on behalf of the National Police Chiefs Council (NPCC) 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, in relation to the prevention of future deaths report sent via email to the NPCC
dated 29th July 2022.
The notice sets out concerns that arose from the information received during the inquest into the
death of Mr Boughton which occurred in November 2021. I am very sorry to read of the circumstances
of Christopher’s death. My sympathies are with his family and friends, and I share your commitment
to addressing the issues you have highlighted.
The notice sets out your principal concern in relation to cross border investigations stating that the
lack of any detailed requirement for telephone discussion between appropriate police officers on
sending through written tasking requests and considering transfers of investigations means that an
opportunity to discuss and ensure smooth transition and passing on of relevant information is lost.
This may cause delay in effective action being taken by the tasked Force, or (in the case of transfers)
by the force to whom it is considered a transfer will be made.
The Authorised Professional Practice (APP) which is the official source of professional practice for
policing states the following in relation to cross-border cases:
Cross-border cases
Difficulties can arise when a person reported missing resides outside the area where the report is
being made, for example, a student in temporary accommodation or a day trip visitor. The police area
that receives the report must record it and carry out all necessary initial actions. If the responsibility
for a case is subsequently transferred to another force area, the rationale for doing so must be
recorded. Written acknowledgement from the receiving force should be obtained.
When deciding where ownership of the investigation lies, the principal issue is to consider where the
majority of the enquiries are and who has the greatest opportunity of locating the missing person. It
is probable that the place where the person was last seen would generate the majority of the initial
enquiries (although this is not always the case, see also Out-of-area placements).
1st Floor, 10 Victoria Street, London SW1H 0NN |
| www.npcc.police.uk
Cross-border enquiries
In cross-border tasking and requests, details of the result of the risk assessment carried out by the
investigating force, and other contextual information, should be passed to forces likely to become
involved in the enquiry. This transfer of information allows colleagues to decide on the focus of their
enquiries.
There is a responsibility on communications staff and investigating officers to request this information.
The officer in charge of the investigation in the initiating force should ensure that all relevant
information, including the risk assessment, is passed to the force that will be managing subsequent
enquiries. It is important that there is a seamless transfer of responsibility for the investigation so that
no cases are missed. The officer making the transfer should check that all materials have been received
in the receiving force and that details of the person who received the information are noted.
Developing a process that includes providing this additional information will reduce the risk to all
involved. All police forces should have email addresses that are available 24 hours a day so that
investigation records can be shared and transferred where relevant.
Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue
you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and
Transfers of Investigations’ has been developed and has now been circulated for comment prior to
finalisation and wider circulation.
I hope that the information that has been provided goes some way to reassure you that the matters
of concern you have raised have been addressed and will be subject to continual review.
For any further information please contact my Staff Officer
who will be happy to address any concerns and answer any questions.
Yours sincerely,
Chair, National Police Chiefs’ Council
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