Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0288, written 15 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Sep 2022 |
|---|---|
| Reference | 2022-0288 |
| Deceased | Harper Denton |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: , COMMISSIONER FOR METROPOLITAN POLICE 1 2 CEO COLLEGE OF POLICING 3 CHAIR OF NATIONAL POLICE CHIEFS' COUNCIL 4 SECRETARY OF STATE FOR DEPARTMENT OF HEALTH AND SOCIAL CARE 5 SECRETARY OF STATE FOR HOME DEPARTMENT 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 2 CORON ER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and I NQUEST On 30 October 2019 I commenced an investigation into the death of Harper DENTON aged 1 Month. The investigation concluded at the end of the inquest on 17 August 2022. The conclusion of the inquest was that: The Deceased was unlawfully killed by her father who had been previously convicted of violent offences against a two year old; failures by state agencies sufficiently to manage the continued high level of risk of his further offending contributed to her death. 4 CIRCUMSTANCES OF THE DEATH On 6 November 2019, imprisonment for her murder. It was not the first time that had brutally attacked an infant; he had previously been convicted of violent offences against a 2 year old child in the Deceased's father, was sentenced to life 2006. Despite being given a 9 year sentence, he was released on licence in July 2010 as dangerous as he had been in 2006; albeit his licence conditions required him not to have unsupervised contact with children under the age of 16 and to disclose details of any new relationships. Following his release in 2012, he came to the attention of the Metropolitan Police Service and was the subject of two CRIS reports involving allegations of Domestic Violence; both reports involved episodes of strangulation. However, there was a lack of information sharing with Probation at this time. He was subsequently recalled to prison for two 6 month periods for breaches of his licence conditions before finally being released for the last time, on 23 June 2014, to Approved Premises accommodation in London with continued restrictions regarding any unsupervised access to children and new relationships, particularly with women and children. At the beginning of December 2014, he moved into private accommodation and, within weeks, was the subject of a MARAC referral concerning further Domestic Violence; although this was co-chaired by the MPS a lack of proper investigation, co-ordination with Probation and serious information failures led to a missed opportunity not only to consider further criminal proceedings but also to identify him as a Potentially Dangerous Person and to manage the high risk he continued to pose accordingly. As a result, later that same year, he started a relationship with the Deceased's mother, moved into her accommodation in Bedfordshire, and the Deceased was conceived without either her mother, Bedfordshire Police, or local healthcare professionals, being aware of the continued risk he posed to her; however, a chance encounter by Bedfordshire Regulation 28 - After Inquest Document Template Updated 30/07/2021 Police on 30 November 2017 was a further missed opportunity for multi- agency safeguarding prior to her death. 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: POLICE 1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance, particularly with respect to PDPs. Because this concern maybe relevant to other police forces nationally, this concern is directed to the CEO College of Policing and the Chair of the NPCC as well as the Commissioner for the MPS. 2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare's Law and Sarah's Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC. HO 3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence. DoHSS 4.The need for a Health Visitor to carry out a full safeguarding assessment of a father's/co- parent's potential risks to a child is currently only 'best practice' and not mandatory. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by October 30, 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Chief Constable of Bedfordshire Cambridge Community Services NHS Trust. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Regulation 28 -After Inquest Document Template Updated 30/07/2021 interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 15/09/2022 ,___ ..,(:~ Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 - After Inquest Document Template Updated 30/07/2021
4 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.
From Neil O’Brien MP Parliamentary Under Secretary of State for Primary Care and Public Health 39 Victoria Street London SW1H 0EU Emma Whitting HM Senior Coroner Bedfordshire and Luton Coroner’s Service Coroner’s Office The Court House Woburn Street Ampthill MK45 2HX 03 March 2023 Dear Ms Whitting, CORONER REPORT TO PREVENT FUTURE DEATHS: HARPER MARIE DENTON Thank you for your letter of 15 September 2022 to the Secretary of State for Health and Social Care, about the death of Harper Denton. I am replying as Minister with responsibility for Health and Secondary Care and I thank you for the additional time allowed. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Harper’s death. I can appreciate how distressing her death must be for those who knew and loved her, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to Harper to prevent future deaths. I am aware that the Police, as well as, the Home Office have responded to you directly on the relevant matters of concern. Therefore, this response focuses solely on your concern related to safeguarding assessments. Health visitors and school nurses as leaders of the Healthy Child Programme have a vital role in keeping children safe. They work with their teams and partners to support local safeguarding arrangements. We are currently updating a set of resources for health visitor and school nurse-led services. This includes emphasising the importance for children who may have additional needs to complete an assessment of family relationships and chronology of events to identify strengths and vulnerabilities. These are due to be published shortly. 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Direct Communications Unit 2 Marsham Street London SW1P 4DF Tel: www.homeoffice.gov.uk Emma Whitting HM Senior Coroner Bedfordshire and Luton Coroner’s Service Coroner’s Office The Court House Woburn Street Ampthill MK45 2HX 2 December 2022 Dear Mrs Whitting Thank you for forwarding a copy of the Regulation 28 report relating to the death of Harper Denton. My experience giving evidence in relation to this tragic case left a powerful impression and my thoughts remain with Harper’s family. The report raised a specific point for the Home Office to consider: (3) There is nothing today, such as a form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence. We are committed to ensuring that the safeguarding system is as robust as it can be. I would like to set out some of the actions under active consideration by the Home Office in relation to the issues raised. Offender Management HM Government is continuing to consider options for better management of domestic abuse offenders. The Tackling Domestic Abuse Plan, published in April, committed to consider the implementation of a domestic abuse ‘register’ to deal with, and effectively manage, the most harmful perpetrators of such offences and reduce the risk they pose. It is anticipated that there will be overlap between those offenders who commit domestic violence and those convicted of specific child cruelty offences, and other offences of violence that may be committed against a child. This sits alongside our ongoing work to improve the management of offenders, including an independent review to evaluate police management of registered sex offenders in the community. The previous Home Secretary appointed former chief constable to look specifically at how the police use their current capabilities to manage the risk posed by registered sex offenders and whether the regime protecting the public from them could be strengthened further. The review concluded in October 2022, delivering recommendations to HM Government on what needs to be done across the policing and law enforcement landscape to enhance the management of registered sex offenders in the community in England and Wales. It is now for Ministers to decide how the findings of the review will be shared and consider any response to the recommendations; including potential implications for work on the development of offence-based ‘registers’. We are also continuing to support disclosure schemes through the provision of national guidance. The Domestic Violence Disclosure Scheme and the Child Sex Offender Disclosure Scheme both provide members of the public with a clear process to seek information from the police on individuals who may pose a risk of harm to children. The Home Office acknowledges the perception that Violent Offender Orders have been sparingly used by the police, and we will be engaging with policing partners to identify barriers to their use and options to promote awareness of their utility. Child Protection reforms You will appreciate that the management of offenders is only one component of the state’s responsibility to keep children safe. To be successful, any development of a child cruelty register would need to complement wider reforms to improve collaboration and information sharing across the key agencies that are responsible for safeguarding children. We know information and data sharing between agencies is a challenge, and across Government we are actively considering how to improve relevant processes for operational partners. The Health and Social Care Act 2022 commits the Government to laying a report before Parliament in Summer 2023 setting out its policy on information sharing by public authorities for the purposes of safeguarding and promoting the welfare of children; including the feasibility of using a consistent child identifier. In May, we welcomed the publication of the Independent Review of Children’s Social Care, and the Child Safeguarding Practice Review Panel’s national review ‘Child Protection in England’; while October saw the final report of the Independent Inquiry into Child Sexual Abuse in England and Wales. All three of those reviews make recommendations to Government on how to improve multi-agency working to strengthen child protection, and taken together provide us with an opportunity to consider how safeguarding can be improved in the round. The Government will be responding to the recommendations in those reviews in due course, and we will continue to consider the case for a child cruelty register in context of all ongoing policy discussions in this space. I hope this letter has been helpful in setting out the ways in which these complex policy questions will be kept under constant review. Yours sincerely, Deputy Director, Tackling Child Sexual Abuse Unit Public Safety Group Home Office 2 Marsham Street, London SW1P 4DF
PROFESSIONALISM HQ
Ms Emma Whitting
Senior Coroner
Bedfordshire & Luton Coroner’s Service
Central Bedfordshire Council Coroner’s Office
The Court House
Woburn Street
Ampthill
Bedfordshire
MK45 2HX
London
Deputy Assistant Commissioner
New Scotland Yard
Victoria Embankment
SW1A 2JL
Our Ref: IX/2241/21
Date: 17 November 2022
Dear Ms Whitting,
Re: Regulation 28 Report to Prevent Future Deaths – Harper Denton
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the
Metropolitan Police Service (MPS). I write to provide the response on behalf of the
Commissioner of Police of the Metropolis to the matter of concern addressed to the MPS in
the Report to Prevent Future Deaths dated 15 September 2022.
On behalf of the MPS may I first of all express my sincere condolences to Harper’s family. Our
thoughts and sympathies are very much with them.
Matter of concern
The MPS does not appear to have adopted ACPO Guidance on Protecting the Public:
Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College
of Policing MOSOVO Guidance, particularly with respect to PDPs. Because this concern
maybe relevant to other police forces nationally, this concern is directed to the CEO
College of Policing and the Chair of the NPCC as well as the Commissioner for the MPS.
Response
There is no legislative definition of a Potentially Dangerous Person (PDP). A PDP is someone
who is not eligible for management under the Multi-Agency Public Protection Arrangements
(MAPPA) as they have not been convicted of, or cautioned for, any offence that would thereby
place them into one of the three MAPPA categories. However, their behaviour gives
reasonable grounds for believing that there is a risk of them committing an offence or offences
that will cause serious harm.
/…
Page 2/Ms Emma Whitting
On a number of previous occasions, the MPS has scoped the feasibility of introducing a PDP
process as outlined in the guidance provided by the NPCC Policing Practice 2017 and College
of Policing Authorised Professional Practice (APP), which superseded the ACPO Guidance
on ‘Protecting the Public: Managing Sexual Offences and Violent Offenders 2010’.
On each of those occasions the MPS has encountered difficulty in two areas;
1. Within London, even after applying strict filter parameters, the sheer number of
nominals who would fall within the definition of a PDP would have made such a process
unworkable.
2. The lack of a legislative framework (as recognised by the APP guidance) proved
problematic particularly with regard to partnership working.
The Commissioner of the Metropolis and individual Chief Constables have operational
independence and so can deviate from the APP guidance if they so choose. In light of the
two difficulties mentioned above, the MPS has not adopted a PDP process to date.
Other than the PDP process, the MPS does have existing mechanisms in place that comply
with other areas of the College of Policing’s (CoP’s) APP for violent offenders. In particular the
use of Category 3 MAPPA and Violent Offender Orders (VOO) where appropriate.
For a person to be treated as a Category 3 MAPPA, they would need to have an existing
caution or conviction for a relevant offence and pose a risk of serious harm to the public.
MAPPA provides a gateway for the MPS and policing generally, to share information with
responsible authorities and other third parties where persons are identified as posing a serious
risk to the public. The MPS is required to follow the statutory MAPPA guidance which exists
to try to ensure consistent application of MAPPA, including considerations of disclosure.
MAPPA provides an information sharing protocol and a mechanism to provide disclosure
based on risk to the public. In all MAPPA Level 2 or Level 3 managed cases, disclosure is a
mandatory consideration.
Common Law powers of disclosure can be used to protect those at risk. To be lawful, any
disclosure must comply with the Human Rights Act 1998, Data Protection Act 2018, the
Rehabilitation of Offenders Act 1974, and established case law. Such disclosure can be to
parents and/or carers of children who may be at risk of harm from a particular person.
The MPS is committed to ensuring that organisational learning from the events which led to
Harper’s murder is captured and addressed appropriately.
The MPS is currently reviewing its existing MAPPA processes. This review will include
consideration of a new scoping exercise to assess the feasibility of introducing a PDP process
as outlined by the College of Policing’s APP Guidance. It is currently anticipated that the
outcome of this review will be completed within six months and will determine whether the
MPS adopts the CoP APP guidance with regard to PDP’s.
/…
Page 3/Ms Emma Whitting
I hope that this response addresses the matter of concern you have raised and that you are
reassured that the issue is being addressed as part of the ongoing review into MPS MAPPA
processes.
Please do not hesitate to contact me should you have any queries.
Yours sincerely
Deputy Assistant Commissioner
Emma Whitting
Senior Coroner
Bedfordshire & Luton Coroner’s Service
Central Bedfordshire Council
Coroner’s Office
The Court House
Woburn Street
Ampthill
Bedfordshire
MK45 2HX
4 November 2022
Dear Ms Whitting,
Re Preventing Future Deaths Report – Harper Denton
Thank you for your report, this was a shocking crime and the sympathies and thoughts of both the
College of Policing and National Police Chiefs Council are with her family.
This is a joint response written on behalf of both the College of Policing (College) and National Police
Chiefs’ Council (NPCC).
You have identified two ‘matters of concern’ for policing to respond to and this response deals with each
in turn.
1) The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing
Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing
MOSOVO Guidance, particularly with respect to PDPs. Because this concern maybe relevant to
other police forces nationally, this concern is directed to the CEO College of Policing and the
Chair of the NPCC as well as the Commissioner for the MPS.
Response
The ACPO guidance from 2010 has been superseded by the College’s Authorised Professional
Practice (APP) on Potentially Dangerous Persons (PDP) which describes the most up to date
professional practice for police forces in England and Wales.
In addition, the College has developed risk principles, vulnerability and risk guidelines and,
principles for the management of potentially dangerous and serial perpetrators domestic abusers.
These guidelines and principles support forces in their identification, assessment and
management of PDPs. College Child Abuse APP is explicit about concerns for a child and the
risk presented by people with a history of violent or sexual offences and makes the links across
to the Management of Sexual or Violent Offenders (MOSOVO) APP.
Chief Constable
is the National Policing Lead for the Management of Sexual Offenders
and Violent Offenders, she drives consistency of policing approaches by supporting forces to
implement guidance and adopt new, promising practice. Additionally, the Vulnerability Knowledge
and Practice Programme (VKPP) actively engages with forces to assist them to assess their own
operating processes and offers coordinated peer support when forces ask for assistance.
However, the Metropolitan Police Commissioner and individual Chief Constables have
operational independence and so can deviate from APP if they choose.
2) There appears to be a lacuna in pro-active information sharing practices by Police
(similar to those found under Clare's Law and Sarah's Law) in order to protect children from those
who may present a threat to them as a result of having previous convictions for violence/cruelty
offences against a child - this concern is directed to the CEO College of Policing and the Chair of
the NPCC.
Response
Where policing becomes aware of a Potentially Dangerous Person, or any person who may pose
a risk to a partner of their children, there is a well-developed legal framework to share information
with a person considered to be at risk of harm, such as a new partner or the parent / carer of a
vulnerable child.
The primary mechanisms for the disclosure of conviction information and, more importantly, risk
information to facilitate child safeguarding, are Multi Agency Public Protection Arrangements, the
Child Sexual Offender Disclosure Scheme and the Domestic Violence disclosure scheme. These
mechanisms provide a statutory and common law approach to enable relevant risk information is
shared proactively and reactively to ensure safeguarding and public protection
Multi Agency Public Protection Arrangements (MAPPA)
MAPPA provides the legal gateway for police to share information with responsible authorities
and a duty to cooperate with agencies such as child social care and / or health. This is to ensure
that individuals identified as posing a serious risk to the public are subject to multi agency
scrutiny and a risk management plan. A plan would include consideration of disclosure of
information to third parties if deemed appropriate. Offenders who have convictions for violence
and cruelty offences against children can be managed within the MAPPA framework. In addition,
the arrangements are subject to statutory MAPPA guidance which aims to ensures their
consistent application.
Child Sexual Offences Disclosure Scheme (CSODS)
Sarah’s law relates to the CSODS and the rights of people who feel that a child may be at risk to
ask about an individual’s convictions for child sexual offences.
Domestic Violence Disclosure Scheme (DVDS)
Claire’s law relates to the DVDS which affords a right to ask as well as a right to tell. Home Office
guidance 2013, provides an explanation of the process to provide increased protection for
domestic abuse victims.
MAPPA guidance provides a non-exhaustive list of offences where convictions and/or allegations
may be disclosed under the DVDS. Although the list is non-exhaustive and is intended to act as
a guide to the types of offences that may be disclosed, it specifically includes Child Cruelty under
Section 1 of the Children and Young Persons Act 1933, Section 1 and 2 Child Abduction, under
the Child Abduction Act 1984, and Causing or Allowing the Death of a Child under Section 5 of
the Domestic Violence, Crime and Victims Act 2004.
Neither of the disclosure schemes are in statute. However, they formalise processes, based on
common law powers of disclosure, to ensure a consistent approach is followed when considering
disclosure of information to individuals when risk is identified to children or of domestic violence.
Any disclosure must comply with the existing legal framework, in particular the Human Rights Act
1998, the Data Protection Act 2018, the Rehabilitation of Offenders Act 1974, and established
case law. Information which may be disclosed includes convictions and out-of-court disposals for
violent offences and / or information about the person’s behaviour which reasonably leads the
police and other safeguarding agencies to believe that the person poses a risk of harm to the
potential victim.
College APP on child abuse refers to the powers of police to share information, and this includes
employers and regulatory bodies. In response to your report the College will, in the next three
months, update APP to make clear that disclosure can also be made to parents and / or carers of
children who may be at risk of harm from a particular person.
APP will be amended to make this common law power clear. An individual with a violence or
cruelty conviction for children therefore should be subject to necessary operational oversight on a
case by case basis and any identified risks shared accordingly.
In conclusion, there are a number of means to share risk related information with statutory and
non-statutory partners including carers of children, where a suspect is identified as posing a risk
to children or others. The uses of these mechanisms and identification of individuals is an
operational responsibility for the chief officer of each force
I hope that this response addresses your concerns regarding this tragic case. The College and
National Policing Lead will ensure that the lessons from the murder of Harper Denton are
disseminated amongst all the police forces of England and Wales.
Yours sincerely
Chief Executive Officer
College of Policing
Chair
National Police Chiefs’ Council
Relevant links to College APP and the VKPP website;
Potentially Dangerous Persons APP
Child abuse APP
Management Of Sexual Or Violent Offenders APP
Vulnerability Knowledge and Practice Programme
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