Hannah Warren

Home Office 

' 

His Majesty's Assistant Coroner Edward Ramsay 

Home Secretary 

2 Marsham Street 
London SW1 P 4DF 
www.gov.uk/home-office 

2.~ April 2023 

Regulation 28 report: Hannah Warren (ref: 127458) 

Thank you for your email of 14 February.  As requested, I am writing to formally respond to 
your report pursuant to the duty in paragraph 7(2) of Schedule 5 to the Coroners and 
Justice Act 2009 and pursuant to the requirements in regulation 29 of The Coroners 
(Investigations) Regulations 2013.  This report relates to the circumstances surrounding 
the death of Hannah Warren in February 2016. 

At the outset, I wish to express my most sincere condolences to Hannah's loved ones for 
the distress they must have experienced following Hannah's death. 

Your report raises a number of concerns about the guidance and training for police officers 
investigating missing person reports;  specifically, the use of the action report (ACT) in 
relation to Hannah's vehicle. 

The police investigation of a missing person report is an operational decision for individual 
police forces.  The standards for these investigations for all forces in England and Wales 
are set by the College of Policing (henceforth 'the College'} through their Authorised 
Professional Practice (APP).  The College also issues guidance for police forces, including 
instructions on the use of ACT and REACT reports on PNC, the most recent version was 
published in  November 2022. 

The College is independent of Government; its role is to set high professional standards 
for policing; sharing what works best; acting as the national voice of policing; and ensuring 
police training and ethics is of the highest possible quality. 

The Home Office has no authority to intervene in operational policing matters.  I cannot 
comment on the action and decisions taken by police officers in the course of their duties 
because operational matters are the responsibility of the Chief Officer of the force 
concerned.  However, for the purposes of this response, my officials have consulted the 
College, the Metropolitan Police and the National Police Chiefs Council (NPCC) to seek 
assurance that the appropriate guidance is in place which addresses the concerns that 
you have raised. 

 
 
 
 I am satisfied by the College that there is current police guidance on this matter which is 
readily available to forces;  and clearly sets out the actions police officers should take were 
these circumstances to arise again.  Specifically, the guidance states that missing persons 
fall into the category of 'serious incidents' and as such, at a minimum, a medium priority 
ACT report should have been put in place.  The response from the College will set out 
further detail on the use of the ACT guidance. 

Thank you for bringing this matter to my attention.  My Ministers and I are committed to 
continuing to work with police forces in England and Wales through the College and NPCC 
to ensure that missing, vulnerable people are protected from harm.  I hope this response 
assures you, and Hannah's family and friends, that your findings are being given the 
appropriate attention in order to ensure that the proper processes are followed should 
these circumstances arise in future missing persons investigations. 

Rt Hon Suella Braverman KC MP

METROPOLITAN 
POLICE 

Mr Edward Ramsay 
Assistant Coroner 
Swansea Neath Port Talbot Coroner's Court 
The Guildhall 
Swansea 
SAl 4PE 

Deputy Assistant Commisioner 
Metropolitan Police Service 
New Scotland Yard 
Victoria Embankment 
London 
SW1A2JL 

21  April 2023 

Dear Mr Ramsay 

I  am  the  Deputy  Assistant  Commissioner  for  the  Directorate  of  Professional  Standards  in  the 

Metropolitan Police  Service ("MPS").  On behalf of the Commissioner of Police of the Metropolis,  I 

write to provide the response to the matters of concern addressed to the MPS in your Report to Prevent 

Future Deaths dated the 13 February 2023. 

On behalf of the MPS  may I first  of all  express  my sincere condolences to  the family .and friends  of 

Hannah Warren, ourthough~s and sympathies are very much with them. 

At the conclusion ofthe inquest into Hannah's death six matters of concern were raised which are listed 

below.  The matters  raised  all  relate to the missing person investigation and the ACT report process 

within  the  ANPR system.  Your report  identified that  whilst  locating the  car  in which  Hannah was 

travelling  would have  been the  most  effective way of locating  Hannah,  the  MPS  use of ANPR and 

specifically the ACT report process was insufficient in order to do so. As a result several opportunities 

to  locate Hannah were missed. The cause of these failings  appear to be due to  a lack of organisational 

guidance and training around ANPR/ ACT report. 

This  letter seeks  to  identify the issues  arising from  each of your concerns,  the action being taken to 

ensure those concerns are addressed in order to prevent future deaths. 

The Coroner's "Matters of Concern'' 

The Prevention of Future Deaths report dated 13 th February 2023 records:-

])  The evidence was clear that the most effective means oflocating a missing person in 

Hannah 's position was to  locate the vehicle in which it was assume_d she was travelling. 

 
 
 
 2)  There was an apparent mismatch between the COMPACT risk assessment for Hannah graded 

as  "'medium" and the LOW stop priority instruction on ACT in relation to her vehicle. 

3)  The evidence I and the jury heard was that there was no formal guidance,  training,  or 

protocols ofany kind to assist with  the dialogue between these two systems; instead,  it was left 

to local custom and practice as to how to  correlate any risk assessment with the priority 

instruction on the ACT, ifat all. 

4)  The preponderance ofthe evidence was that the LOW stop instruction was inappropriate in 

.this case,  but I was not directed to any document or guidance tha~ would have assisted those 

responsible at the time for selecting the correct priority on the ACT. 

5)  I have seen no evidence ofany formal guidance,  training,  or protocols as to how these two 

critically important systems are meant to operate alongside one another safely, or at all. 

6)  This appears to  be a national issue and is not related solely to  the lack ofany formal 

guidance,  training,  or protocols within the MPS specifically. 

The MPS accepts that is should consider matters (1) to (5), our response to these matters of concern is 

as follows: 

ANPR and ACT reports. 

i. 

The'·Automatic Number Plate Reader (ANPR) system is a national system which is used for a variety of 

vehiible  related  functions  ranging  from  the  management  of  car  park  tariffs  to  Road  Traffic  Act 

compliance. The system allows  authorised bodies to retrieve vehicle and owner information from the 

Driver and Vehicle Licensing Agency (DVLA) for lawful purposes. 

Due to its  national coverage,  the ANPR system has been identified as  a  vital tool  for  police services 

when dealing with both crime and vulnerable persons where a vehicle is involved.  The Action Report 

(ACT) process was developed by Police National Computer (PNC)  Services to enable police forces to 

identify and provide real time location data for those vehicles where the police force requires some form 

of action to be taken should they come to notice.  Adding an ACT report to a vehicle record will trigger 

the inclusion of that vehicle into the ANPR fast track pool. 

When to Use an ACT Report 

An ACT report should be used where it is reasonable and proportionate for that vehicle to-be subject of 

national circulation for the purpose of appropriate action being taken should the vehicle come to notice, 

or when  an  intelligence  marker  normally  circulated  as  an  entry  on a  Vehicle  of Interest  (VOi)  list 

contains warning signals which may compromise officer safety.  There is an expectation when adding 

an ACT report that some form of action will be taken should the vehicle be sighted. This action may be 

to 'STOP' the vehicle, 'MONITOR' the movements ofthe vehicle pending advice or specialist support, 

 or 'ASSESS' the situation at the time ofthe sighting and make an informed decision whether to stop the 

vehicle, or for an alternative response to be taken. 

The police force  originating the circulation must be prepared to provide assist,;mce  should the vehicle 

be  stopped and the requested  action taken in another  force  area.  This  could potentially be anywhere 

within England, Wales, Scotland, Northern Ireland, Guernsey, Jersey or the Isle· of Man. 

When entering an ACT report, as well as the action required, a risk assessment must be completed which 

highlights the level ofrisk or harm to the subject to assist the police force or officer taking action to take 

the appropriate response.  These priority levels are set out in MPS policy (2019) as: 

•  High Priority - to be used in the most serious of cases and in particular where life is at risk. 

•  Medium Priority - to be used for major, serious or complex investigations 

•  Low Priority -.to be used for  volume crime,  priority investigations  and road traffic  offences 

where a vehicle and/or the occupants need to be traced. 

Missing Persons 

The  College  of Policing  Missing  Persons  Authorised  Professional  Practice  (APP)  sets  out  clear 

processes and procedures for investigating these cases, risk assessments and risk management processes. 

The APP gives guidance to police forces regarding the way missing persons are risk assessed, which is 

High, Medium or Low.  This risk assessment must be recorded on the relevant  reporting system - the 

MPS  use the Merlin system (Missing Persons  & Related Linked  Indices).  The MPS  notes  the term 

1 COMP ACT has been used in the Regulation 28 report, when referring to the missing person risk grading. 

COMP ACT is the missing person reporting system used by South Wales Police. 

The  College  of Policing's  APP,  provides  the  following  guidance  regarding  missing  person  risk 

assessments: 

•  High risk - The risk of serious harm to the subject or the public is assessed as very likely. 

•  Medium risk - The risk of harm to the subject or the public is assessed as likely but not serious. 

•  Low risk- The risk of harm to the subject or the public is assessed as possible but minimal. 

Once the investigating officer completes the risk assessment, it must be confirmed by an officer of at 

least the rank of Inspector as  soon as practicable. 

With regard  to  the  circumstances,  Hannah Warren was  reported  missing by her  fiance  and  flatmate 

having gone missing from within the M~S.  Hannah was graded and confirmed as a medium risk missing 

person on the MPS  Medin system,  this  decision has not been questioned in the regulation 28  report. 

Investigating officers  identified that the ANPR system would provide the greatest chance of ldcating 

 Hannah.  However, when the ACT report was created in relation to Hannah's vehicle it did not appear 

to reflect the risk grading and/or concerns for Hannah's vulnerability. 

Based  on the priority definitions,  'Low priority'  for  a vulnerable  missing person would  now  not  be 

appropriate. The ACT report was also lacking in sufficient detail to direct the identifying polic€ force 

or officer to take appropriate actiori.  This meant that despite Hannah's vehicle activating a number of 

ANPR cameras several opportunities to intercept her were missed. The MPS were unable to provide to  · 

HM Coroner details of any training in place for Officers surrounding the creation of ACT reports. 

MPS action 

Following consultation with the College ofPolicing, it is accepted at the time ofHannah's death in 2016 

there  was  no  organisational  guidance  or training  in place  for  officers  around  the  ACT  and  REACT 

(Reaction - once the action has been taken) report process ofthe ANPR system.  Within the MPS, there 

was no service level agreement (SLA) regarding governance and oversight ofthe content currently held 

within the ANPR system. 

In November 2022, the College ofPolicing published the Information and ComIIiunications Technology 

(ICT)  learning  document  "ACT  and  ReACT  reports  on  PNC".  The  document  is  a  Home  Office 

approved  training  tool  aimed  at  frontline  officers  and  supervisors,  it  details  all  aspects  of the  ACT 

process and responds  to the  failures  and knowledge gaps  identified during the inquest  into Hannah's 

death. 

The MPS  Learning and Development directorate are in the process of adapting this national guidance 

into  a  MPS  training package,  which  will  be  delivered  to  all  frontline  officers  digitally  via the MPS 

Learning Management System. A key focus ofthe training will be to identify to all users the importance 

of ensuring the priority grading,  information and request  contained within an  ACT report  accurately 

reflects the risk presented by the subject or situation,  and where this  risk is  documented (i.e.  missing 

person report or crime report).  The user must understand the link between the risk associated to the 

subject and the priority rating of the ACT report as this is crucial to.ensuring that the appropriate 

response is taken. 

The MPS commenced the training design and development in March 2023, it is anticipated the training 

will take up to 12 months from conception to completion. 

In addition to the requirement to  train and develop  all  users  of the ANPR system and ACT process, 

Hannah's death has highlighted the lack of governance and ownership of intelligence submitted in the 

ACT report process and held within the PNC. 

 To  improve  the  accuracy  of ACT  report  submissions,  risk  assessments  and  to  ensure  the  ongoing 

management ofthe information held on the system, the MPS will shortly be introducing a new a Service 

Level  Agreement  (SLA).  This  requires  all  low  and  medium  priority  ACT  reports  to  have  been 

authorised by an officer of at least the rank of inspector prior to submission ( currently only high priority 

reports require a superintendent's authority).  In addition, all ACT reports must have nominated contact 

who is available 24hrs per day and suitably informed to provide updates and direction in the event of an 

activation.  It  will  be the responsibility of the  owning officer to  review  and remove  entries  from  the 

system, ifthey are no longer required.  The SLA is awaiting final approval, for publication in May 2023. 

Please do not hesitate to contact me should you have any queries. 

Yours ·sincerely,

Mr Edward Ramsay, 
HM Assistant Coroner, 
HM Coroner for Swansea and Neath Port Talbot 
The Guidhall 
Swansea 
SA1 4PE 

5th April 2023 

Re Death of Hannah Warren 

Dear Mr Ramsay, 

This response is submitted on behalf of the College of Policing and National Police Chiefs’ Council.  

Thank you for your Regulation 28 – Preventing Future Deaths report relating to the death of Hannah 
Warren.  The College of Policing and NPCC offer our condolences to Hannah’s family and friends.  

Hannah’s death happened in 2016.  Since that time our instructions and guidance on managing missing 
persons enquiries and the use of PNC and ANPR have been reviewed and updated.  

Missing Persons Authorised Professional Practice (APP) sets out clear processes and procedures for 
investigating these cases including the risk assessment and risk management processes that should be 
followed. The Regulation 28 report does not contain a great deal of detail on the circumstances of 
Hannah going missing, but, on the information available, it seems reasonable for her to have been 
graded a medium risk missing person. There then seems to have been action taken to trace her, 
including the updating of PNC and creation of the ACT alert. 

The issue in this case arises because of the nature of the ACT (an abbreviation of ‘action report’) alert.  
Current College instruction on this system is clear- 

“An ACT report should be used where it is reasonable and proportionate for that vehicle to be 
subject of national circulation for the purpose of appropriate action being taken should the vehicle 
come to notice or when an ANPR intelligence marker normally circulated as an entry on a Vehicle 
of Interest (VOI) list contains warning signals which may compromise officer safety. 

There is an expectation when adding an ACT report that some form of action will be taken should 
the vehicle be sighted. This action may be to STOP the vehicle, MONITOR the movements of the 
vehicle pending advice or specialist support, or ASSESS the situation at the time of the sighting 
and make an informed decision whether to stop the vehicle, or for an alternative response to be 
taken. 

 
 
 
 
 
 
 
 
 
 
 
 
 The force originating the circulation must be prepared to provide assistance should the vehicle be 
stopped and the requested action taken in another force area. This could potentially be anywhere 
within England, Wales, Scotland, Northern Ireland, Guernsey, Jersey or the Isle of Man.” 

There is then content on levels of risk and response- 

LOW 

For volume crime, priority investigations and RTC offences where a vehicle 
and/or occupants need to be traced (taking account of the circumstances where 
ACT is not to be used). 

MEDIUM 

For major, serious or complex investigations 

HIGH 

In the most serious of cases and in particular where life is at risk.  

This needs the authorisation of a Superintendent (or equivalent). In the event of 
a Superintendent (or equivalent) not being available an Inspector (or equivalent) 
can authorise, but this MUST be approved by a Superintendent (or equivalent) 
within 24 hours. 

Hannah would clearly not have fallen into the low risk category (RTC is short for ‘road traffic collision). A 
vulnerable missing person is specifically listed as a ‘serious investigation’.  

If a medium or high ACT report is added, there must be one of three words to start the report indicating 
the activity that a force should undertake if there is a relevant ANPR activation.  These words are – Stop, 
Monitor or Assess (as described in the above extract).  

‘Monitor’ should only be used in exceptional circumstances, usually in circumstances when specialist 
resources are needed to stop the vehicle and occupants in a safe manor (e.g. should there be concerns 
about weapons in the vehicle).   

‘Assess’ should only be used where there is ‘…credible information to indicate that the vehicle is being 
used to support criminal activity and that it is determined as reasonable and proportionate for the vehicle 
to be the subject of a national circulation.’ 

Neither ‘monitor’ nor ‘assess’ would be appropriate in Hannah’s case.  

‘Stop’ would be the appropriate word and this should result in the following response- 

This should be used when the circulating force require officers to stop the vehicle and take action 
as described in the body of the report.  

Should an incident similar to Hannah’s happen today, the current ACT instructions should be followed 
and the ACT report noted with an instruction to STOP. Had this happened in 2016, Hannah’s vehicle 
would have been appropriately noted on the PNC and ANPR ACT systems and she would have been 
stopped, with there being clear instructions on what action the officers stopping her should have taken.  

I hope that this response is sufficient to deal with your concerns about the missing persons and ACT 
systems.  NPCC will ensure that the issues apparent in Hannah’s case are raised through the 

 
 
 appropriate portfolio areas. This will help to ensure that, should a similar incident be investigated today, 
the correct actions and responses would happen. 

Yours sincerely 

Chief Constable 
Chief Executive Officer 
College of Policing 

Chief Constable 
Chair 
National Police Chiefs’ Council (NPCC)