Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0071, written 23 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Feb 2023 |
|---|---|
| Reference | 2023-0071 |
| Deceased | Anthony Ingram |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: National Police Chiefs’ Council 1st Floor, 10 Victoria Street London SW1H 0NN 1 CORONER I am Nigel PARSLEY, HM Senior Coroner for the coroner area of Suffolk 2 CORONER’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 INQUEST On 7th April 2022 I commenced an investigation into the tragic death of- Anthony John Raymond INGRAM The investigation concluded at the end of the inquest on 26th January 2023. The conclusion of the inquest was that:- Anthony Ingram, died as the result of suicide The medical cause of death was confirmed as: 1a Hanging 4 CIRCUMSTANCES OF THE DEATH Anthony Ingram was found deceased at his second home in Westleton, Suffolk, on the 29th March 2022. When found, Anthony was inside the property, suspended by a rope around his neck. Anthony lived in London, and his mental health had been deteriorating over a period of time. On 29th March 2022, at approximately 13:30 Anthony left London and headed towards his second home in Suffolk. Anthony was known to be in possession of rope and a ‘collapsible’ bicycle when he left. The information regarding the rope and the bicycle was not passed to Suffolk police at the time the case was reported to them. At 17:50 a Suffolk officer attended Anthony’s second home but did not enter although keys were available from a neighbour. Anthony’s vehicle was not present, and the officer formed the opinion that he had insufficient information to enter the premises under Section 17, Regulation 28 – After Inquest Document Template Updated 30/07/2021 Police and Criminal Evidence Act at that time. Shortly after this time, Anthony’s vehicle was found in a car park more than two miles from his second home, and police search activity was focussed there. At approximately 20:00, once Suffolk officers became aware that Anthony had a rope, and the search of the car park area had failed to locate him, they returned to the second home and entered, finding Anthony deceased. The collapsible bicycle was found in the hallway. Poor communication between the Metropolitan Police and Suffolk Constabulary meant that the officers on the ground were missing information which would have informed their decision making regarding the search for Anthony and informed their use of police powers. This resulted in a missed opportunity to find Anthony earlier than he was found. 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: Evidence was heard from police officers from both the Metropolitan Police and Suffolk Constabulary. The officers provided evidence of the details they respectively held regarding the missing person investigation surrounding Anthony’s disappearance from London and subsequent death. It was clear that crucial information (that Anthony had a rope in his possession, and a collapsible bicycle providing a secondary form of transport) was not passed between the Metropolitan Police and Suffolk Constabulary. It was heard that there was no set format, or prescribed information requirements to be shared by officers reporting missing persons between one force and another. Investigating officers in the Metropolitan police spoke to the Suffolk Constabulary control room, whose staff logged what they were told onto the CAD record. This information was then relayed to the officers on the ground. Witnesses in this case stated that there is no standardised information sharing requirement or protocol for cross border missing persons investigations (including missing persons with suicidal ideation). I am concerned that, as there is no standardised information sharing requirements or protocols in such cases, in the future a force receiving details of a suicidal missing person may also not be informed that an individual has taken a means of suicide with them. In addition, other important information that may assist in the search for that person may also not be passed. 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 April 20, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 1. 2. 3. Anthony’s next of kin. Chief Constable for Suffolk The Commissioner Metropolitan Police 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 interest. You may make representations to me, the Senior Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 23/02/2023 Nigel PARSLEY HM Senior Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Nigel Parsley
HM Senior Coroner for Suffolk
The Suffolk Coroner’s Service
Beacon House
Whitehouse Road
Ipswich
Suffolk
IP1 5PB
Date: 11th April 2023
Dear Mr Parsley,
Regulation 28 Report – Mr Anthony John Raymond Ingram
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 23rd February 2023.
The notice sets out concerns that arose from the information received during the inquest into the
death of Mr Ingram which occurred in March 2022. I am very sorry to read of the circumstances of
Anthony’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 missing person investigations
stating that crucial information was not passed between forces as there is no standardised information
sharing requirements or protocols in such cases.
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 to all forces for
consultation.
In addition to the above The National Transfer form is being updated to include a section to be used
for requesting enquiries in another force. One of the new recommendations is to require the officer
requesting the enquiries or transfer to contact by telephone or video call the key decision-maker in
the other force so that the level of risk and urgency of enquiries can be effectively communicated,
rather than rely on what is written on an email or the incident log. We are still waiting for the new
form to be completed, but there is a working party completing that task and it is anticipated that it
will be available in the next few weeks when the new processes will go live.
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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