Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0109, written 8 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 | 8 Nov 2023 |
|---|---|
| Reference | 2024-0109 |
| Deceased | Lee Bowman |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (East) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Officer, College of Policing CORONER lam Abigail Combes, Assistant coroner, for the coroner area of South Yorkshire (East District) 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 12th January 2022 I commenced an investigation into the death of Lee Bowman born on 10th January 1977. The investigation concluded at the end of the inquest which commenced on the 8th November 2023. The conclusion of the inquest was:~ An open conclusion In box three it was recorded On 2 November 2021 Lee Bowman was reported missing to police by his family. The last sighting of him was on 31 October 2021. His body was found at 62 Green Arbour Road, between two fence panels in the garden on 3 January 2022 The medical cause of death was: 1a: Unascertained 4 CIRCUMSTANCES OF THE DEATH Lee Bowman was last seen by his family on 29 October 2021 going to his girlfriend's home address in South Yorkshire. His family did not hear from him after this and that was out of character for Lee who would ordinarily be in touch with his family hourly during the day. Lee did not possess his own phone and therefore family had to rely on Lee contacting them rather than being able to ring him themselves. Lee had a number of underlying health conditions including mental health conditions and history of self harm. He also had recently had a diagnosis of liver cirrhosis which was causing him concern. On top of that his father had recently been diagnosed with cancer and that had upset him. 1 On 31 October 2021 Lee was reported as being seen in the vicinity of his girlfriend's home address with injuries consistent with being assaulted. This is the last unquestioned sighting of Lee before his body is found. On 2 November 2021 Lee was reported missing to Nottinghamshire Police by his brother. His brother reports that they haven't heard from him and that this was out of character for Lee. He also makes reference to mental health problems and that he has not taken it well that his father has been diagnosed with cancer. Nottinghamshire Police determined that this is not a true missing person enquiry at this stage as it is not clear that he is actually missing, and they asked South Yorkshire Police to make enquiries at the last known address that Lee was going too. The log that Nottinghamshire police hold is updated before the addition of information from South Yorkshire police confirming that they had attended at his girlfriends address and she said she had kicked him out two days previously. The matter then returned to Nottinghamshire Police who closed the incident down as a deliberately absent individual. On 4 November 2021 Lee's father also reported Lee missing as they had still not heard from him. This commenced the missing person investigation from Nottinghamshire Police. There were a number of sightings reported of Lee when media appeals were issued. These were both in South Yorkshire and Nottinghamshire. These were not necessarily thoroughly checked for accurateness although they were followed up by officers in Nottinghamshire. These sightings gave false assurance that Lee was well and was not contacting family for unknown reasons. The sightings included a sighting by a police officer and this check was assessed as being particularly reliable however there was insufficient scrutiny applied to that veracity of that sighting. In any event, that sighting was in early November still leaving days unaccounted for. There was no referral to detectives from Nottinghamshire Police and instead the investigation was transferred to South Yorkshire Police on 28 November 2021. This was closed by South Yorkshire Police as a result of an incorrectly confirmed sighting by a PCSO of Lee. The case was reopened by South Yorkshire Police on 7 December 2021 following a call from Lee's family confirmed that he had still not been seen. When the case was reopened on the 7 December 2021 and then reviewed on the 9 December with the grading being low risk. This was revisited on the 10 December and despite no particular change to the circumstances it was revised to be Medium risk. On 14 December 2021 the missing person report was regraded as high as it was apparent that the sightings were unconfirmed sightings. This resulted in detectives being asked to lead the investigation who undertook a number of enquiries including CCTV, door to door enquiries and financial and phone enquiries. It appears that it was not until 31 December 2021 that the police in South Yorkshire became aware of the jacket which Lee was wearing in the last known sighting, being found and that narrowing the search scene to near where Lee was ultimately found. 2 Between Lee's reported disappearance on 2 November 2021 right up until his body was found on 3 January 2022 there had been no activity in Lee's bank account and no contact with his family despite his usual levels of contact with them. gave evidence that there were four possible medical explanations for Lee's death:- 1. Liver disease 2. Hyperthermia 3. Drug or alcohol use 4. Positional asphyxia However, he also explained that there was not enough pathological evidence to be persuaded by to give a preference and for that reason he had to return unascertained and rely upon the inquest to try and ascertain the circumstances. There was no evidence heard during the inquest that assists with the circumstances beyond Lee having been seen with injuries in the vicinity of where his body was found on 31 October 2021 . was clear that Lee had been where he was found for some time but could not be precise as to when he had died. The following findings were made during the inquest: - The decision making around the closure of the Log created when Lee was first reported missing on 2 November 2021 was lacking in clarity and has been largely based on presumption. The log appears to have been closed before the clarity has been received from South Yorkshire Police about whether or not Lee was at his partners address and seems to be based upon intelligence information held by the police rather than risk assessment of the current situation which Lee was in at the time that he went missing. That said, even if the log had remained open and a missing persons case been commenced it is apparent that a key factor for Nottinghamshire police's risk assessment when Lee was reported again on 4 November was the fact that his money had gone into his account on 3 November but that it had not been touched. This would not have been the case on the 2 November and therefore it cannot be confirmed whether that would have made a difference to the searches that were conducted for Lee on that date. On the basis of on 2 November 2021. evidence, it cannot be said whether Lee was already dead The checks conducted by South Yorkshire Police on 2 November 2021 lacked professional curiosity. When it was confirmed that Lee had been kicked out of the house and not seen since there was no sense that this might require any additional follow up or any further enquiries made of his then partner about whether he was ok w hen he left the address. Whilst this is unlikely to have made a difference to the overall outcome it was a missed opportunity to gather information and intelligence about Lee's condition at the time he was a missing person. There was evidence of unconscious bias influencing the decision making and judgments of officer's risk assessing. For example, there were assumptions that Lee led a chaotic lifestyle and therefore was not missing but choosing not to be found as he was drunk somewhere. This was never triangulated with the fact that he had not touched his bank account and even within the confines of his addiction, he ordinarily maintained contact with his family which he did not do here. 3 Police also relied upon sightings from those who lead similarly 'chaotic' lives to demonstrate that Lee was well and just had not been located. Again, this was not weighed against the body of evidence from the family that he was unwell and was not in contact with them which was out of character. Once detectives took over the inquiry on the 14 December 2021 matters picked up in PACE and enquiries were undertaken with greater clarity and order however in reality nothing had substantially changed in Lee's position in that time. What was discovered in December 2021 was that the sightings relied upon in fact could not be relied upon and had not been adequately scrutinised. Unfortunately, the evidence from the pathologist was such that it cannot be said when Lee died and therefore the point at which he could still have been found alive cannot be identified. The decisions in respect of the searches therefore cannot be said, even on the balance of probabilities, to have made a difference to the outcome for Lee. 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 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: - 1. There were significant assumptions made about the whereabouts of Lee and the reasons for his failure to contact family. The assumptions were based on the facts of Lee's addiction which on one view ought to have been identified as a vulnerability, on another view were wholly irrelevant in the context of his family confirming he was in daily contact until 31 October 2021. Insufficient weight was placed on the information provided by Lee's family about his current state of mind and ordinary behaviours. Although there was a THRIVE assessment undertaken by the call handler on 2 November 2021 when the first missing person report was made, the burden of the weight fell on his PNC record and police intelligence information painting a picture which was not representative of the concerns of his family. 2. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 the 4th 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 l have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Lee Bowman, Deputy Chief Constable of West Yorkshire Police as the National Police Chief Council Lead for Missing Persons, Home Office, Chief Constable of South Yorkshire and Chief Constable of Nottinghamshire 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. 4 I may also send a copy of your response to any other 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 coroner, at the time of your response, about the release or the publication of your response. 9 ath November 2023 Mrs A Combes, Assistant Coroner 5
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.
Abigail Combes Assistant Coroner - South Yorkshire The Coroners Court and Office Crown Court building College Road Doncaster DN1 3HS 3 January 2023 Dear Mrs Combes, Regarding the death of Lee Bowman Thank you for your Regulation 28 Notice of 8th November 2023 relating to the tragic death of Lee Bowman. As always in these cases, our thoughts are with his family and friends. Thank you for your work to uncover the facts of the incident and to look to improve responses to missing persons in the future. The College of Policing has been in contact with officers from Nottinghamshire and South Yorkshire Police forces as well as liaising with Deputy Chief Constable Hankinson, the national policing lead for Missing People on behalf of the National Police Chiefs’ Council. The College of Policing has extensive guidance contained in its Authorised Professional Practice (APP) on Missing People Missing persons | College of Policing. The APP supports all forces of England and Wales to manage missing persons enquiries. The document focuses extensively on the need for accurate risk assessment with actions to trace a missing person being based on the assessed level of risk. There are other College documents and training that are also relevant to the way in which policing responds to reports of missing people. Our training product on vulnerability and risk, for example, is a day long course for police responders that emphasises, when dealing with calls for service from the public, the importance of investigating a person’s circumstances fully so that any policing response can be based on comprehensive understanding of the vulnerabilities of an individual and the risks of harm that may result from those vulnerabilities. There is significant content across a range of College products about the need to recognise one’s own values and biases and how these can affect decisions. For example, our content relating to stop and search specifically calls attention to the risks of unconscious bias and how this can lead to unfair use of police powers. Similar content can be found in our content on dealing with vulnerability related risks. The issues related to unconscious bias and the need for careful, balanced risk assessment are recognised within the College of Policing and across the police service. Your second matter of concern refers to reliance on PNC and intelligence records. Unfortunately, the report to us contains no detail of what was in these records or any commentary on why investigators gave them greater weight. It is, therefore, difficult for us to respond to these particular circumstances. However, the College has recently published Evidence Based Guidelines on Risk Assessment Vulnerability-related risks | College of Policing. This document is based on a broad range of research and sets out clear guidance on how to carry out risk assessment and is based on risk principles Risk | College of Policing. It emphasises the importance of gathering information from a range of sources to inform a decision maker’s professional judgement about the level of risk and what action should be taken to address that risk. Your report also mentions the lack of activity in Mr Bowman’s bank account. Police find it very difficult to acquire information from financial institutions except in high-risk cases – in this context, ‘high risk’ refers to fears of very serious injury or death. In the case of Mr Bowman, the risk of harm was assessed as high after the passage of a significant period of time. Inactivity on his bank account could have led to his risk being raised earlier, but there is a Catch 22 – the risk of harm could have been raised because of the lack of bank activity but the lack of activity could not be identified without the case being assessed as high risk. This is a broader issue than Mr Bowman’s case but does indicate the difficult environment in which policing sometimes operates. There were of course other (non-financial) indicators of risk in this case, such as the family’s concerns about lack of contact, but we feel it useful to point out that, sometimes, not all sources of help (such as financial data) are accessible to police and this can lead to inefficiencies in investigations. In reading your report, our subject matter expert was troubled by the term ‘chaotic lifestyle’ that appeared to have been used in some of the risk assessments. Terminology such as this is imprecise and invites readers of such comments to assign their own assumptions to what the term means. We will update our Missing Persons APP to alert police officers and staff to the need to avoid such value laden but imprecise terms. Instead, they should set out clearly and simply what matters and issues have been identified that have a bearing on the assessment of risk. I hope that this response addresses your matters of concern. We will continue to support policing to improve responses to missing persons. Yours sincerely Chief Constable Chief Executive Officer College of Policing
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