Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0479, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Nov 2023 |
|---|---|
| Reference | 2023-0479 |
| Deceased | Gracie Spinks |
| Coroner | Matthew Kewley |
| Coroner area | Derby and Derbyshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Constable of Derbyshire Constabulary 2. The Rt Hon James Cleverly MP, Secretary of State for the Home Department 1 CORONER I am Matthew Kewley, Assistant Coroner, for the coroner area of Derby and Derbyshire. 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 21 June 2021 I commenced an investigation into the death of Gracie Elizabeth Spinks (“Gracie”) who was 23 years old when she died on 18 June 2021. The investigation concluded on 16 November 2023 at the end of the inquest heard with a jury. The jury concluded that Gracie was unlawfully killed by a former work colleague on 18 June 2021. 4 CIRCUMSTANCES OF THE DEATH Gracie was born in 1997. In 2020 Gracie started working for a company in Chesterfield called Xbite. Whilst working at Xbite, Gracie met up on a number of occasions outside of work with a male colleague who was employed as a supervisor at Xbite. Gracie decided that she did not want to have any sort of relationship with the supervisor and made this clear to him in December 2020. The supervisor failed to accept Gracie’s decision and became obsessed and fixated with her. Gracie reported the supervisor’s behaviour to Xbite in January 2021 and he was subsequently dismissed from Xbite in February 2021. Gracie also reported the supervisor’s stalking behaviour to Derbyshire Constabulary in February 2021. A police investigation was carried out which resulted in no action being taken against the supervisor. The supervisor was given ‘words of advice’ by the investigating police officer. In May 2021 a member of the public found a rucksack containing multiple weapons on a public footpath near to the field where Gracie kept her horse. The member of the public was concerned about the contents of the rucksack and reported this to Derbyshire Constabulary. The attending police officers treated the rucksack as if were simply an item of found property and failed to carry out any form of investigation into the rucksack and its contents. On 18 June 2021 Gracie was unlawfully killed by the supervisor who she had reported to Derbyshire Constabulary in February 2021. Gracie died as a result of a stab wound to 1 the neck. It was established after Gracie’s death that the rucksack found by the member of the public in May 2021 containing weapons belonged to the supervisor who killed Gracie. At the inquest into Gracie’s death Derbyshire Constabulary accepted that there were multiple serious police failings in respect of the stalking investigation in February 2021 and the rucksack incident in May 2021. Those failings were recorded by the jury on the Record of Inquest but it could not be determined that those failings contributed to Gracie’s death on 18 June 2021. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Derbyshire Constabulary: in investigating Gracie’s stalking complaint 1. Stalking – during the inquest I heard evidence from the police officers who were involved in February 2021. Derbyshire Constabulary accepted that there were serious failings in how Gracie’s complaint was investigated by these officers. I do recognise that Derbyshire Constabulary has taken some steps following Gracie’s death to improve knowledge around stalking. However, as the Detective Chief Superintendent who gave evidence for the Constabulary accepted, more needs to be done to improve knowledge and understanding around how officers should investigate complaints of stalking. Consideration may be given to: • Reviewing the current force guidance/training on stalking and considering whether further guidance/training is required in light of the issues identified during the inquest (including consideration of whether there ought to be a force policy on stalking); • Re-enforcing understanding of the existing training/guidance on stalking including consideration of further training sessions/briefings to emphasise the key issues around investigating complaints of stalking, particularly in relation to the need to investigate the stalking complaint fully in order to identify potential patterns in the suspect’s alleged behaviour; • Ensuring officers are aware of the available resources on stalking and, crucially, the importance of actually consulting the available resources on stalking when police officers are investigating stalking cases to ensure that investigations are conducted in line with expected standards. 2. Risk assessments – during the inquest I saw a number of good quality risk assessments completed by police call handlers/officers who were involved in the very early stages of Gracie’s stalking complaint in February 2021 and also the rucksack incident in May 2021. However, it became apparent during the inquest that the police officers who were subsequently allocated to deal with the stalking complaint and the rucksack incident failed to record any form of risk assessment 2 or fully assess the potential risks. As was recognised by the Detective Chief Superintendent who gave evidence for the Constabulary at the inquest, the crime report for the stalking investigation in February 2021 lacked any sort of risk assessment or even a recognition of potential risks. I heard evidence from the police officers involved in the stalking investigation and the rucksack incident and I am concerned that there may be an ongoing lack of understanding about the importance of completing comprehensive risk assessments which include the initial identification of risk and also, importantly, a regular re-assessment of risk as the investigation progresses. I consider that further steps should be considered in order to improve understanding and appreciation of the importance of completing comprehensive risk assessments. 3. Independent Office for Police Conduct (“IOPC”) – the IOPC carried out an investigation into the conduct of the five officers involved in the stalking investigation and the rucksack incident. The IOPC made a number of recommendations to Derbyshire Constabulary which included: ‘2. To consider how stalking offence locations are recorded on Niche. There does not appear to be any guidance to suggest that all of the locations of the stalking offending are tagged to the incident individually. In this instance it may not have made any difference as the officers who received the bag did not do a search of police systems for the area. However, in future that may well be done, and it could make the difference between linking risk and suspects.’ I heard evidence about this issue from the Detective Chief Superintendent on behalf of the Constabulary and I am concerned that more needs to be done to engage with this specific recommendation from the IOPC. The inquest heard that specific geographical locations can be particularly important in stalking investigations (i.e the horse field in Gracie’s case). As such, it seems to me that the IOPC recommendation is an important one which could assist in future cases with linking suspects and particular locations relevant to the stalking investigation. 4. Contemporaneous note taking/record keeping – during the inquest I heard that police officers failed to make any contemporaneous notes of important steps in the police investigation including, for example, conversations with an informant/member of the public, words of advice given to a suspect, a telephone call to a potential witness and also an internal police discussion between a police constable and police sergeant discussing the closure of an investigation. The written crime reports reviewed during the inquest also lacked sufficient detail around these important conversations/investigative steps – in other words, the crime reports did not compensate for the lack of contemporaneous notes. I am concerned that a lack of contemporaneous notes/insufficient detail within a crime report may impact on the ability to make properly informed risk assessments which rely on the existence of a good written record of important conversations/steps taken during an investigation. This may become an issue where, for example, an investigation is re-allocated to another police officer who has had no prior involvement in the investigation such that the newly allocated police officer will be reliant upon the quality of the original police officer’s records/notes. 3 5. Potential weapons/dangerous items found in the community – during the inquest I heard that police officers attended to a report of a rucksack containing weapons found by a member of the public in May 2021. Despite the rucksack containing weapons, it was treated by the attending police officers as if it were an item of found property. Derbyshire Constabulary accepted that there were serious failings in how the officers dealt with this incident. During the inquest, I heard that there has been another recent incident around 11 August 2023 in which a child found a knife concealed in bushes in a local park. The knife was concealed in a sock and the child’s parent was concerned that the knife had been concealed so that it could be used at a later date. Despite the obvious potential danger, the police call handler advised the member of the public to ‘destroy’ the knife and advised that police would not be attending. Whilst I recognise that further steps have been taken very recently in response to this latest incident, I am concerned that there appears to be an ongoing issue within Derbyshire Constabulary around the ability of some police officers/staff to deal effectively with reports of potential dangerous weapons found in the community. The Rt Hon James Cleverley MP, Secretary of State for the Home Department: 6. Independent Stalking Advocates – during the inquest I heard evidence about the benefits that stalking advocates can provide to those who are victims of stalking. Whilst I was reassured to hear that Derbyshire now benefits from stalking advocates, I heard evidence that many other areas around the UK do not have stalking advocates. This essentially creates a postcode lottery for victims who report stalking to the police. I am concerned about the lack of consistency and availability of stalking advocates to victims of stalking across the UK. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 22 January 2024. 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: • Gracie’s family • Derbyshire Constabulary I have also sent it to the following individuals who may find it useful or of interest: • • • , National Police Chief Council Lead for Stalking and Harassment , Police and Crime Commissioner for Derbyshire , MP for Chesterfield 4 I am also 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, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Matthew Kewley Assistant Coroner for Derby and Derbyshire 27 November 2023 5
2 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.
:
Date:
22 January 2024
Dear Mr Kewley
I am writing in response to your report dated 27th November 2023, following the inquest into the
death of Gracie Spinks on 18th June 2021 in Derbyshire. We welcome the opportunity to update
you on the changes the force has made to improve its response to stalking since 2021, and to
inform you of the other actions we have taken, or propose to take, in response to your report. In
doing so we again reiterate our sincere condolences to the family and friends of Miss Spinks.
In your report, you note five areas of concern. These are outlined and addressed as follows
below.
1. Knowledge and understanding of stalking and how officers should investigate complaints of
staking, in which consideration may be given to:
• Reviewing the current force guidance/training on stalking and considering whether further
guidance/training is required in light of the issues identified during the inquest (including
consideration of whether there ought to be a force policy on stalking);
• Reinforcing understanding of
including
consideration of further training sessions/briefings to emphasise the key issues around
investigating complaints of stalking, particularly in relation to the need to investigate the
stalking complaint fully in order to identify potential patterns in the suspect’s alleged
behaviour;
training/guidance on stalking
the existing
• Ensuring officers are aware of the available resources on stalking and, crucially, the
importance of actually consulting the available resources on stalking when police officers
are investigating stalking cases, to ensure that investigations are conducted in line with
expected standards.
As a force, we are committed to improving our staff’s understanding and identification of stalking
and vulnerability. Since the inquest, we have reviewed and refreshed the content of our training
on stalking as part of the force’s vulnerability programme. This emphasises to our officers and
staff the risk indicators of stalking behaviour and the importance of pursuing all reasonable lines
of enquiry. A focus is also placed on the importance of broadening intelligence parameters to
include multiple locations to assess cumulative risk, and that officers should undertake ongoing
risk assessments throughout the course of an investigation and keep accurate records.
Derbyshire Constabulary, Headquarters, Butterley Hall, Ripley, Derbyshire, DE5 3RS
Incoming telephone calls and communications may be monitored and recorded.
2
The force is delivering the revised mandatory stalking training to all frontline police officers and
staff. This commenced on 11th January 2024 and is expected to be completed by April 2024.
The force will monitor attendance, undertake an evaluation of the training, and ensure it forms
part of continued professional development (CPD) for officers and staff in the future.
During January 2024, we have also updated the force’s training products which are delivered to
student officers, to ensure their inputs are current and take cognisance of the learning points
highlighted within your report.
A full review of the force’s available resources on stalking was undertaken in December 2023,
updating key points on multiple locations being assessed to identify potential patterns in a
suspect’s behaviour. Forcewide messages have been issued to officers and staff, raising
awareness of the availability of these resources to aid and inform investigations.
To formalise the existing guidance on stalking, Derbyshire Constabulary is due to publish a new
stalking policy in February 2024. The policy has been reviewed, amended and sent out for
consultation with key stakeholders across Contact Management, Divisional and Crime functions
across the force. We have drawn upon and used best practice from other forces to formulate
the policy. The policy specifically sets out the expectations required in response to stalking,
supported by a standard operating procedure that provides clarity on the working practices and
processes to be followed. This will include a specific checklist for officers to consider as part of
the investigation strategy, including wider crime pattern analysis, multiple offence locations and
the importance of adopting an ‘investigative mindset’ when pursuing all reasonable lines of
enquiry.
The launch of this policy will be delivered by a specific communications plan to ensure that all
staff are fully informed of the changes and expectations. The policy will also be published
externally on the force website.
In March 2023, we developed a quality assurance framework in respect of investigations, known
as Quality Assurance Thematic Testing (QATT). Through this framework, investigations are
quality assured by officers of inspecting ranks across the organisation, focusing on the quality
of investigation plans, victim care, suspect management, and effective supervision.
This framework allows the force to review a cross section of investigation types, with an ability
to include specific areas of focus such as stalking. Established processes within the QATT
framework ensure officers and their supervisors receive feedback from the case audits, including
being signposted to relevant guidance and policy where required.
QATT performance outcomes are monitored through force performance meetings, providing
scrutiny and oversight at a senior level. During January 2024, all crime audits will relate to
stalking investigations, providing a deeper assessment of the quality of investigations and the
impact of the ongoing training being provided.
We recognise that to embed the learning from Miss Spinks’ death, cultural change is needed.
The force’s strategic investigation strategy has been reviewed and 2024 is focused on the key
theme of ‘investigative mindset’ and pursuing reasonable lines of enquiry.
We are collaborating with the National Police Chiefs’ Council’s stalking and harassment lead
Deputy Chief Constable
, to undertake an independent peer review of the force’s
policies, procedures, and training material.
A tabletop exercise relating to stalking and harassment will be held in March 2024 with
attendance from subject matter experts, including senior investigators and stalking advocates.
3
This forms part of our stalking improvement plan to better understand the victim’s journey and
make appropriate improvements as a result of learning shared from the exercise.
2. Risk assessments, particularly a lack of understanding about the importance of completing
comprehensive risk assessments which include the initial identification of risk and also,
importantly, a regular re-assessment of risk as the investigation progresses.
The force is focused on improving the consistency and quality of risk assessments. Staff in our
Contact Centre undertake a regular programme of training, reinforcing the completion of Thrive
risk assessments which are used identify the threat, harm, risk, investigative opportunities,
vulnerability, and engagement opportunities which are present when responding to incidents.
Audits conducted by His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services
(HMICFRS) in October 2023, have shown that in 64 of 66 cases the call handler has provided
a structured, accurate and meaningful Thrive risk assessment.
Since 2021, the force has introduced a Domestic Abuse Review Team (DART) to undertake
secondary risk assessments of all domestic abuse, stalking and harassment (DASH) risk
assessments. Similarly, in 2022, we created a new role, a stalking coordinator, to undertake
secondary risk assessments of non-domestic related stalking. The purpose of these functions
is to undertake an objective assessment of the risk, considering the cumulative risk from
previous incidents or reports.
During the force’s 2023 PEEL Inspection, by HMICFRS, the quality and consistency of such
assessments was inspected, and some areas for improvement were found. As a result, the force
has immediately responded and throughout December 2023 we further trained our dedicated
DART team to ensure a greater focus is placed on psychological harm and patterns of
behaviour. We are currently working with Safe Lives, a nationally recognised charity within this
field, who will offer further inputs in February 2024 along with an independent audit of risk
assessments the following month, to independently evaluate the changes that have been made.
Further changes were implemented in December 2023 to improve the consistency and
timeliness of submitting risk assessments for stalking cases. The previous form 90 risk
assessment, which was used in non-domestic abuse stalking investigations, was a stand-alone
form, separate to other force risk assessments. This has now been integrated into the DASH
risk assessment form, known as a DASH public protection notice (PPN), meaning there is now
one process for assessing both domestic and non-domestic stalking. The Control Room policy
is now to no longer close incidents until such risk assessments have been completed and
endorsed on the log. This is overseen by supervision from line managers.
The force has engaged other forces to identify best practice in respect of risk management of
stalking. This has informed our proposal to develop a multi-agency stalking intervention panel.
We are working with agencies, including the probation service, health professionals, fire service,
children and adult social care, independent support services and stalking advocates to establish
a multi-agency panel. The panel seeks to enhance the management and safety planning of
stalking cases through considering the specific circumstance of each case, and coordinating
appropriate interventions, both in terms of the safeguarding of victims and tackling perpetrator
behaviour to reduce the risk of further offending. Although engagement with agencies continues,
we are seeking to introduce this by June 2024.
Regular risk assessments are required to be undertaken throughout an investigation and these
expectations are clearly outlined in the force’s crime management policy. This is now monitored
through the force’s QATT framework (as described earlier).
4
A thematic review of stalking investigations between June 2023 and November 2023 has been
undertaken. Unfortunately, this demonstrated a continuing need for improvement, and the
revised training material, together with effective supervision and oversight is reinforcing this. The
Thrive policy is being refreshed in January 2024 to include a greater focus on the ongoing need
for ‘re-Thrive’ assessments during an investigation, and the expectation for this to be fully
documented on the crime report.
The force is evaluating the impact of the work being undertaken and the changes to policy with
a further thematic audit throughout January 2024, to assess performance in this area, which
shall be reviewed at the force’s strategic Performance Assurance Board, chaired by the Deputy
Chief Constable.
3. Independent Office for Police Conduct (IOPC) recommendation to be fully considered,
namely:
• To consider how stalking offence locations are recorded on Niche. There does not
appear to be any guidance to suggest that all of the locations of the stalking offending
are tagged to the incident individually. In this instance it may not have made any
difference as the officers who received the bag did not do a search of police systems for
the area. However, in future that may well be done, and it could make the difference
between linking risk and suspects.
In 2016, Derbyshire Constabulary adopted Niche as its Crime Management System. It is used
across the force for investigation and case management, safeguarding referrals, intelligence
submissions, property management and custody management. To ensure we can identify
patterns and trends, the system relies on data being flagged or linked. Prior to December 2023
the force had been unable to link multiple locations to a crime report, due to a lack of
functionality. However, following the recommendation made by the IOPC the force has worked
with Niche and other police forces to introduce this functionality, which is now available following
a system upgrade. These changes took effect in November 2023 and notification of this has
been communicated to the force via the Chief’s Orders, a circular, on 11th December 2023 and
reiterated in January 2024, on the force intranet.
In addition, the force’s command and control system, which records calls for service, dispatches
officers and records attendance, is due to be replaced in July 2025. The new system will provide
new capability across our telephony and command and control functions, including the ability to
tag multiple locations. Its automated intelligence functions have improved capability, providing
a greater amount of information to inform risk assessments, identifying more effectively repeat
callers and locations without the need to search multiple systems. In the meantime, intelligence
officers support call handlers, through assessing information linked to wider locations, as part of
an incident’s initial intelligence assessment.
4. Contemporaneous note taking/record keeping, particularly a lack of contemporaneous
notes/insufficient detail within a crime report may impact on the ability to make properly informed
risk assessments which rely on the existence of a good written record of important
conversations/steps taken during an investigation.
All officers receive core training for investigation as part of the Professionalising Investigations
Programme (PIP), at level 1 for volume and priority crime and level 2 for those investigating
more serious and complex investigations.
This builds investigative skills, in which the importance of effective record keeping is threaded
throughout. Specifically, the conducting investigations module, national decision model module
and Criminal Procedure and Investigations Act (CPIA) and disclosure training inputs all
5
emphasise the importance of record keeping, noting the significance of rationale and actions
taken for accountability.
Since the inquest, the importance of contemporaneous note taking and record keeping has
formed part of key messaging, through senior management teams, to frontline staff and
supervisors. This area of learning has also been incorporated into the training material that has
been refreshed. Officers have access to mobile devices upon which contemporaneous notes
can be made.
Building upon this, as mentioned above, the force’s Improving Investigations strategy has been
reviewed and refocused for 2024, in which building an ‘investigative mindset’ is a key priority. A
series of workshops are underway throughout January and February 2024, with senior leaders
as well as frontline officers and staff, to understand the capabilities required and opportunities
to improve the desired behaviour.
This includes a focus on behavioural change as well as process improvement. Within the
delivery plan, is a focus on reinforcing the requirements to maintain robust and comprehensive
record keeping, understanding the importance of note taking from both an evidential and risk
management perspective. This will be governed through the Strategic Improving Investigation
Board, chaired by the Head of Crime, and incorporated into the QATT framework for
performance monitoring.
5. Potential weapons/dangerous items found in the community, and a concern that there
appears to be an ongoing issue within Derbyshire Constabulary around the ability of some police
officers/staff to deal effectively with reports of potentially dangerous weapons found in the
community.
In 2021, the force issued guidance for responding to reports of found property. In October 2023,
the force reviewed its policies in respect of property, realigning the earlier guidance through
introducing a specific policy relating to found weapons. An audit of found property incidents
between October 2023 and December 2023 has been undertaken. There is still more
improvement needed to ensure revision of risk at all appropriate stages and divisional senior
management teams are reinforcing expectations regarding the standards of investigations
required in such cases, in accordance with the policy. The ongoing audit and performance
monitoring shall remain in place until working practices are to the required standard. The Deputy
Chief Constable will monitor these.
Further to the inquest we have introduced a Gold Group chaired by the Deputy Chief Constable,
to review the recommendations within the Prevention of Future Deaths report, understand the
issues raised and take appropriate action. This group shall remain in place to track progress
against the recommendations. I hope the above response provides you with the assurance of
the actions taken by the force since 2021 and its continued efforts to improve the service we
provide to our communities in respect of stalking.
Yours sincerely
Chief Constable
Home Office Matthew Kewley HM Assistant Coroner for Derb shire Home Secretary 2 Marsham Street London SW1 P 4DF www.gov.uk/home-office lg' January 2024 ank you for sending the Report to Prevent Future Deaths on 27 November 2023 regarding the tragic death of Gracie Spinks. Before I respond in turn to the important points you raise in your report, I would like to foremostly recognise that at the heart of this inquest is Gracie Spinks and I speak directly to her bereaved family when I express my deepest condolences for their loss. Stalking is an appalling crime that has a devastating impact on victims, and this is something the Government takes extremely seriously. In your report, you raise concerns regarding the lack of consistency and availability of Independent Stalking Advocates (ISAs) to victims of stalking across the UK. The Government recognises the value of this support and has provided additional funding to stalking charities for victims. The National Stalking Helpline, run by the Trust with part-funding from the Home Office provides advice and advocacy services for victims. The Ministry of Justice are also quadrupling funding for victim and witness support services by 2024/25, up from £41 m in 2009/10. At the local level, the Ministry of Justice provides grant funding to Police and Crime Commissioners to commission support services for victims of all crime types, based on their assessment of local need. Police and Crime Commissioners can also use core funding to directly fund stalking advocates in their local area providing additional specialist support and advice. However, I am open to exploring whether more needs to be done to recognise and promote this important specialism. This is why the Government is continuing to explore with relevant stakeholders, such as the National Stalking Consortium, where Government intervention could improve the criminal justice response to stalking and support for stalking victims, including within the Victims and Prisoners Bill. The Bill continues its passage through Parliament with Committee stage in the Lords beginning on the 24 January where we welcome further debate on this area. I would also like to respond to some of the wider points made in the report in relation to the police response to stalking. The Home Office regularly works with the National Police Chiefs' Council to raise awareness among police officers of the available guidance and training on stalking. I have also asked officials to review the Home Office statutory guidance on coercive and controlling behaviour (CCB) so it makes clear what the differences are between CCB and stalking, allowing officers to respond appropriately. I have also asked officials to work with the National Police Chiefs' Council to gather examples of best practice in terms of policing stalking cases, to share with forces and support them with their force policies on stalking. I thank you for raising the important issues in your report. I would like to assure you that the Home Office is fully committed to tackling the crime of stalking and is dedicated to doing all that it can to protect victims and to robustly target perpetrators.
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