Michaela Hall

Information Classification: CONFIDENTIAL  

14 June 2024 

Mr Andrew Cox  

Senior Coroner for Cornwall and the Isles of Scilly 

Cornwall Coroners' Service 

Pydar House 

Pydar Street  

Truro  

TR1 1XU 

Dr Mr. Cox, 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

On behalf of Cornwall Council We would like to express our sincere condolences to Michaela’s 

family. We are continuing to work with colleagues through the Domestic Homicide Review process 

to identify actions stemming from the Senior Coroner’s proposed recommendations.   

In the regulation 28 report provided to the Council by the Senior Coroner, the following matters of 

concern and recommendations are recorded in respect of the death of Michaela Hall: 

Cornwall Council  |  

www.cornwall.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1.  Do  not  delineate rigidly  between  adults  and  children  but  consider  the  family  as  a  whole. 

Where appropriate and permitted in law, share information between services; 

2.   Record in writing a rationale for reaching a view that there are no eligible care and support 

needs;  

3.   Record in writing why a safeguarding (s42) enquiry may not be progressed on a statutory 

footing but on a non-statutory basis instead;  

4.   When considering a victim of domestic abuse, complete a needs assessment even when 

consent is not forthcoming;  

5.   If  no  eligible  care  and  support  needs  are  identified,  take  a  step  back  and  consider  the 

exercise of discretion;  

6.   When relevant information is shared from a family member or health-related information is 

received,  ensure  this  is  acted  upon  and  shared  appropriately  between  Council  services 

and wider agencies.  

7.  Be curious. There were multiple examples of potential mental impairment – a diagnosis of 

OCD,  mentions  of  suicidality  and  depression,  the  Acton  email,  yet  no  health-related 

enquiries appear to have been undertaken. 

This report is a response to the Senior Coroner in respect of these matters. 

For ease of reference, we have responded to each concern in order, with the exception of points 

4 & 7 which have been considered together. 

1.  Do  not  delineate  rigidly  between  adults  and  children  but  consider  the  family  as  a 

whole. Where appropriate and permitted in law, share information between services; 

There are mechanisms for information sharing between Together For Families (TFF), made up of 

children’s  and  families  services,  and  Adult  Social  Care  (ASC).  This  includes  an  awareness  of 

respective safeguarding arrangements and referral routes – the adult Multi Agency Safeguarding 

Hub  (MASH)  and  the  Children’s  Multi  Agency  Referral  Unit  (MARU)    as  well  as  ongoing  work 

between practitioners.  

 
 
 
 
 
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The purpose of the MASH is to discuss with wider agency partners referrals which Adult Social 

Care receive. This enables swift multi agency information sharing. The MARU is the Multi Agency 

Referral Unit. This is the referral for mechanism for concerns in respect of children. Following the 

inquest  and  the  Senior  Coroner’s  findings  we  have  taken  the  opportunity  to  reinforce  to  team 

managers  and  practitioners  within  ASC,  the  need  to  share  concerns  and  information  with 

colleagues in TFF.  The ASC practice framework references the whole family approach as a key 

tenet  of  our  practice  in  Cornwall,  identifying  our  awareness  of  the  importance  of  considering 

individuals in the context of their families. 

The whole family approach identifies a best practice approach for practitioners working within ASC 

to consider the needs of the whole family when carrying out assessments and developing care and 

support plans. The whole family approach encourages Local Authorities to take a holistic view of the 

individuals needs and consider this in the context of both their support network and wider community 

and  how  these  could  contribute  towards  the  individual  achieving  their  identified  outcomes.  In 

conjunction with this, Local Authorities must also consider how any identified needs of the individual 

are impacting on the family members or others in their support network. The guidance highlights that 

in order to make whole family approaches a reality in practice, four key steps are required which are 

to  

1. Think family: this involves identifying the impact of the individuals care needs on the family.  

2. Get the whole picture, which includes assessing the needs of the person and their carers' needs 

for support.  

3.Make a plan that works for everyone.  

4.Check that it is working for the whole family by carrying out an outcomes-focused review 

In  Cornwall,  we  encourage  our  practitioners  to  use  the  whole  family  approach,  supported  and 

underpinned by our Strengths Based and Person-Centred approaches and training offers. We also 

have a specific commissioned support for both Adult Carers and Young Carers. In addition, all of our 

practitioners  receive  regular  safeguarding  training  which  supports  them  to  identify  and  raise  any 

issues or concerns which may relate to both children and adults appropriately. Following the inquest 

and the Senior Coroner’s findings, we have taken the opportunity to remind and reinforce with all 

Children’s  Services  managers  and  practitioners  about  existing  arrangements  in  place  to  seek 

 
 
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support for victims of domestic abuse; the MARAC referral process; and the Safer Futures advice 

line, which is available to provide professional advice and support around domestic abuse. We have 

asked  all  practitioners  across  Children’s  Services  to  consider  carefully,  and  discuss  with  their 

managers,  whether  any  additional  adult  safeguarding  referral,  and/or  MARAC  referrals,  are 

appropriate for any adults they are working with.  

We now ensure that we have dedicated representatives from Adult Social Care at MARAC.  Lunch 

and Learn events have been held to increase the awareness and knowledge of MARAC within the 

directorate.  

As part of our commitment to increasing the confidence and capabilities of Children’s Services 

practitioners to take a whole family approach and recognise and respond effectively to domestic 

abuse and its impact upon children, we have invested in a full time Family Domestic Abuse 

Support Advisor (Family DASA) for each of our nine Family Assessment and Support teams, in 

partnership with First Light, a specialist domestic abuse provider. Family DASAs provide specialist 

advice, consultation and direct interventions with families where a risk of domestic abuse is 

identified in children’s social care referrals and/or social work assessments. In addition to the main 

Safer Futures advice line, this means that children’s services practitioners have the option of 

talking through any worries or concerns with our Family DASAs. 

In children’s services assessments and planning, all children are considered as being part of a 

family,  acknowledging  the  complexity  of  the  families  and  communities  we  support  and  their 

potential to be part of other groups. Increasingly the wider (extended) family is incorporated into 

assessments and planning. All Early Help and social worker assessments are family assessments. 

Most plans are family plans, with the exception of Child in Care plans and Pathway Plans, which 

related to individual children in line with statutory guidance for children in care and care leavers.  

2.  Record in writing a rationale for reaching a view that there are no eligible care and 

support  needs  and  record  in  writing  why  a  safeguarding  enquiry  may  not  be 

progressed on a statutory footing but on a non statutory basis instead 

We  have  produced  practice  guidance  for  managers  and  assessing  staff  as  to  the  level  of 

information around an individual’s needs to make a decision on eligibility under the Care Act and 

 
 
 
 
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how this is to be recorded on documentation. Similarly, we have developed a template for staff 

working within the safeguarding triage function to ensure that they correctly record their rationale 

for decision making.  

As discussed during the inquest there were issues with the accuracy of record keeping within the 

safeguarding concern  in  respect  of the threshold  decision  making.   We  are  satisfied that  these 

were down to the mis-selection of radial buttons rather than a misunderstanding of the member of 

staff in regard to the legislation and decision making. However, we have taken this opportunity as 

recorded above to ensure that staff within safeguarding triage use the decision-making template 

to demonstrate their rationale for decision making within safeguarding concerns.  

Equally, MARAC actions are now recorded on Halo for auditing and flagged to the MARAC chair 

when not competed.  

3.  &  7  When  considering  a  victim  of  domestic  abuse,  complete  a  needs  assessment 

even when consent is not forthcoming, and be curious in its undertaking 

We accept the threshold to assess a person’s needs is a low one and there is a further duty under 

S.11 to assess those at risk of abuse or neglect regardless of consent for those who are unable to 

safeguard themselves. However, the areas of assessment are clearly set out within Regulationsi and 

are  around  general  social  care  needs  including  nutrition,  personal  care,  home  environment  and 

access to the community.  

Given the limitation of the assessment, the burden of increased needs assessments may not provide 

any notable improvement for those subject to domestic abuse and, in view of the limited resources 

of  the  local  authority,  may  divert  precious  resources  from  service  provision.  The  Council 

commissions specialist domestic abuse services which are not reliant on eligibility under the Care 

Act for access.  

 
 
 
 
  
 
  
 
 Information Classification: CONFIDENTIAL  

Safeguarding triage has been receiving an ever-increasing volume of referrals over the past 4 years. 

The service now often receives between 900 and 1000 concerns a month. Whether or not a Care 

Act assessment is indicated is a key role of the safeguarding triage function and, if indicated, this 

recommendation would be passed to the locality teams.  

Nevertheless, the Council accepts the finding of the Senior Coroner, that a Section 11 assessment 

should be considered in all cases where we are aware of domestic abuse and that the rationale for 

assessing or not assessing should form part of the social care record particularly in relation to the 

appearance of need and the ability of the individual to safeguard themselves.  In this regard we have 

contained  within  the  practice  guidance  referenced  above,  the  importance  of  including  a  clear 

rationale for decision making within assessment documents if an assessment is not progressing for 

any reason.  

Understanding coercive control and the impact of domestic abuse upon an individual’s capacity to 

consent or participate is key to such an assessment and decision.  An emerging area of evidence, 

knowledge, understanding and skills that professionals have yet to be adequately informed about.  

Government strategy recognises that tackling domestic abuse is a cross–departmental and multi-

agency responsibility. The Care Act statutory guidance on safeguarding includes coercive control. 

This means that a Local Authority’s duty to make (or ask others to make) safeguarding enquires 

and determine what action is needed is triggered by ‘reasonable cause to suspect’ that an adult 

with care and support needs is experiencing coercive control (where their needs prevent them from 

protecting themselves). 

Not all practitioners may recognise coercive control when responding to safeguarding concerns, 

particularly in domestic abuse situations. There is a need to apply professional curiosity, and 

consider inherent jurisdiction, in such circumstances by asking relevant questions to ascertain what 

the adult is actually experiencing in order to ensure they are able to access the right support.  

It is important for professionals to understand that controlling and coercive behaviour is not 

separate to violence, but that violence or fear of use of violence is a tactic used by the perpetrator 

to control the victim. It is also important to understand that the impact of coercive and controlling 

behaviour on victims can and will affect their own behaviours. Family members may notice a 

change in their daily activities, how they dress, whether they socialise. The impact of the domestic 

 
 
 
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abuse may also affect the victim’s usual decision-making processes, for example they may make 

decisions to pacify the perpetrator to avoid further abuse. These decisions may appear confusing 

and irrational to family members and professionals. Professionals should consider the impact of 

coercive and controlling behaviours on a victim in terms of their decision-making processes and 

any potential impact on their capacity to make safe decisions for themselves. This should be 

recorded in case notes and any rationale for undertaking (or not undertaking) an assessment. A 

practice guidance note has been written to support practitioners with their understanding and 

awareness of coercive control. We now audit 30 cases a month within ASC as an additional 

assurance in respect of the quality of our practice to ensure that the guidance and training we 

produce is producing anticipated improvements in practice.  

Similarly, we are evolving our understanding of how multiple, co- occurring conditions can impact 

ability to consent and participate (in this instance Compulsive Obsessive Disorder, depression and 

suicidality). In Safeguarding terms, the cumulative impact of these should be considered, alongside 

coercive control and other forms of domestic abuse, as having cumulative impacts upon capacity, 

the ability to engage and consent, rather than seen as separate issues. 

We have recently completed our Practice Framework within Adult Social Care. It instructs workers 

to be holistic, collaborative and enquiring in their practice to ensure that they are responsible for 

drawing out the information they require rather than passive receivers of information. This would 

include making enquiries with other agencies it was believed to have been in touch with 

individuals. 

Within the structure of our teams there are multiple opportunities for social workers and social work 

practitioners to discuss the individuals they are working with the peers and managers. This 

provides a blend of both formal and peer reflective supervision which is a key social work tenant.  

5.  If no eligible care and support needs are identified, take a step back and consider the 

exercise of discretion;  

Where an adult is not identified as having care and support needs there is no legal duty to 

provide for those needs under section 18 of the Care Act 2014. The Council nonetheless has a 

power to meet an adult’s needs for care and support: section 19(1) of the Care Act 2014. That 

power  can  be  exercised  prior  to  any  needs  and  section  13  eligibility  assessment  having 

 
 
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been undertaken if the Council considers that an adult’s suspected needs for care and support 

appear to be urgent (s.19(3) Care Act 2014). 

Cornwall Council commissions services for adults who have needs for care and support which 

do not rely on an assessment of eligibility under the Care Act. These include the provision of 

specialist domestic abuse services. Within Cornwall this service is provided by Safer Futures, 

who provide a single point of contact for anyone in Cornwall or the Isles of Scilly who has 

experienced domestic abuse and requires support. This support includes advice, education, 

recovery and behaviour change programmes for people affected by domestic abuse and sexual 

violence.   

Since Michaela’s death a Domestic Abuse outreach team has been commissioned. This team works 

intensively  with  people  who  traditional  service  provision  often  struggles  to  engage.  This  includes 

those with multiple vulnerabilities. The outreach team have deliberately low caseloads so they can 

offer  flexible  support  in  a  way  that  meets  the  needs  of  the  individuals.  We  are  working  to  bring 

together the domestic abuse, drugs and alcohol, and homelessness outreach teams as one system, 

to enable one trusted professional to progress the relationship with the individual (such as Family 

Domestic Abuse Support Advisor and Independent Domestic Violence Advocates).  This is part of 

an ongoing culture shift to ensure that organisations feel confident to work together as one team and 

is a focus of commissioned services in Cornwall. Currently, all professionals try to engage with an 

individual and offer support from their service area.  There is a level of coordination at MARAC and 

via information sharing between agencies.  The team-around-the-professional approach will allow 

one  lead  professional  to  coordinate  and  deliver  integrated  support  to  the  individual.  The  trusted 

professional will work in a team-around-the-professional approach to safety plan and also to ensure 

the voice of the victim is heard through the professional with whom the victim is engaging. 

6. When relevant information is shared from a family member or health-related 

information is received, ensure this is acted upon and shared appropriately between 

Council services and wider agencies.  

We are aware of our ability to receive and record information about individuals. Under 

safeguarding legislation we are able to share information with relevant partners in certain 

 
 
 
 
 
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circumstances. 

We have taken this opportunity to remind operational managers and staff of the need to consider 

all the information available when commencing work with an individual and that safeguarding takes 

precedence over information sharing concerns. 

Since Michaela’s death MARAC have implemented the following with an aim to improve engagement 

with victims, and to better capture vital information known to families;  

Adjustments are being made to improve the information gathered for MARAC cases via the MARAC 

case management  system to  more formally  capture the voice  of the  victim  and family.  There  are 

additional text boxes being added to the MARAC Research Form that captures wishes and feelings 

of the abused. 

The  commissioned  domestic  abuse  service  (Safer  Futures)  is  currently  reviewing  their  practices 

around family involvement and looking at ways to improve how they approach consent and employ 

curiosity around service users' more comprehensive support networks. When the review has been 

completed  recommendations  will  be  identified  and  implemented.  Where  there  is  consent,  the 

Information  Commissioners  Office  (“ICO”)  and  General  Data  Protection  Regulation  (“GDPR”) 

guidance  will  be  utilised  to  show  that  the  information  gathered  and  recorded  from  the  family  is 

captured on a lawful basis. This information will then be fed into the safety planning process through 

MARAC. The victims expressed wishes would be listened too and considered alongside risk.  

It is the aim of the MARAC to empower victims to have a voice and some control over the process, 

after so many have often lost control in many aspects of their lives due to the domestic abuse they 

have experienced.  

Safer Cornwall, with Safer Futures, are exploring a pilot around ‘affected others’ groups which would 

provide support to family members of those impacted by domestic abuse. This is in its infancy and 

an  evaluation  would  sit  alongside  the  pilot,  but  it  is  hoped  this  would  provide  much  needed 

information and advice to family members to enable them to feel more confident in supporting their 

loved ones. We will also be looking at whether information for families can be accessed via the Safer 

Futures  website  to  enable  them  to  gain  information  and  advice  on  how  to  support  their  family 

members. 

 
  
  
  
  
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Finally, we would like to take the opportunity to thank you for highlighting these matters of concern 

and for giving us the opportunity to respond. We will continue to work with all our partners to support 

the residents of Cornwall. 

Yours sincerely,  

Strategic Director, Care and Wellbeing 

i The Care and Support (Eligibility Criteria) Regulations 2015 SI 2015 No.313

Information Classification: CONTROLLED 

T/ Assistant Chief Constable 

Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ 

    31st May 2024  

Dear Mr Cox 

Michaela Hall – Prevention of Future Deaths Report   

I write further to your letter dated 3 April 2024 enclosing Prevention of Future Deaths 
Report.   I am grateful for the additional time to provide this response.  

Please accept this letter as the formal response submitted on behalf of Devon & 
Cornwall Police under Rule 29 Coroners (Investigations) Regulations 2013.  

I have carefully considered your Judgement and specifically your findings of fact set 
out between paragraphs 301 – 332 thereof.   I note you have helpfully set out the 
three primary areas dealing with issues relating to Devon & Cornwall Police as 
follows: 

1.  Offender Management. 
2.  The emergency response. 
3.  The entry issue.  

Devon & Cornwall Police welcomes the opportunity for learning and the opportunity 
to consider ways in which we can enhance efforts to safeguard vulnerable members 
of our community.  

As you have expressed, circumstances surrounding the relationship between Ms 
Hall and 
was a challenging context in which to operate.   

 caused difficulties in the effective safeguarding of Ms Hall and 

Where victims of DA are unsupportive of police action, this creates a challenging 
environment for police to work in.   Devon & Cornwall Police officers have a number 
of tools available to them which were explained during this inquest, and I hope to 
expand on below.  

In response to your Prevention of Future Deaths Report, and with the intention of 
providing reassurance to you and the family of Ms Hall,  I set out here an overview of 
the ongoing work to tackle Violence Against Women and Girls (VAWG) and 
specifically tackling Domestic Abuse (DA).  

 
 
   
 
                                                                    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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VAWG is now a national Strategic Policing requirement and a control strategy priority 
within Devon & Cornwall Police, with a dedicated strategic and tactical lead. DA has 
a dedicated portfolio lead and is a significant priority within the force’s response to 
VAWG.  Ongoing work continues as part of the VAWG strategic priority to enhance 
safeguarding for victims of DA.  

Work ongoing includes:  

Evidence Led Prosecutions (ELP) 

A review of the use of and process for Evidence Led Prosecutions (ELP) is 
underway.   

This will involve oversight and scrutiny of ELP data to also include scrutiny of data 
which will enable us to better understand the causes of those cases which are not 
proceeded with under an ELP and to reflect on these.   

As a result of this work, further guidance will be produced for all police officers to 
supplement their training and understanding of seeking ELPs.   It is intended that this 
enhanced data and guidance will assist the force in understanding and further 
supporting those victims who feel unable to support a prosecution.  

Domestic Abuse Operational Procedure 

In addition, a new DA Operational Procedure is currently under development.  This 
document takes on board learning from avenues such as Domestic Homicide 
Reviews and HMICFRS feedback and will aim to support the force in tackling DA 
effectively. It will include guidance in relation to (but not limited to) positive action, 
Public Protection Notices (PPNs), DVPN/Os, MARAC, coercive & control and non-
fatal strangulation. 

Operational Procedure for DVPN/DVPOs 

A revised Operational Procedure for DVPN/DVPOs, has also been produced for all 
officers dated 8 May 2024 to support the understanding and use of these protective 
civil orders.     

New Opportunities  

•  Rapid Video Response (RVR) – a pilot providing additional service provision 
is currently in operation. This provides an immediate response to a victim of 
domestic abuse, subject to certain criteria being met. A member of the public 
calling into 101 will have their call assessed and providing they meet suitable 
criteria; they will be immediately transferred to a live video call with a police 
officer. A dedicated team is currently in place to provide this level of service. 
•  Vulnerability Risk Assessment Review – a review of potential improvements 
to the quality of PPNs which could be made and potential addition of a 
secondary risk assessment.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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•  Evidence Led Prosecution guidance – proposed additional guidance for 

officers focusing on improving the response for victims who cannot/fear to 
support a prosecution (as mentioned above) 

•  Additional DA training – to include input to Detective Sergeants’ training in 
addition to the College of Policing requirements (this is already underway).  
•  Additional DA Matters training with Safelives – initially for Moonstone officers 
(the Domestic Abuse Investigation & Safeguarding Team)  with the intention 
for this to be rolled out further.   

•  DA Champion training – to supplement the DA Matters training.  Roll out 

• 

scheduled for June 2024 to support the reinvigoration of the DA champion 
network. 
In addition, already implemented as a priority within Force Tasking is the 
oversight of performance data and monitoring of the early arrest of 
perpetrators of DA. 

I hope the above information provides reassurance that, as a force, Devon & 
Cornwall Police continue to look for opportunities to support victims of domestic 
abuse, to include where they do not feel able to support police action.   This is acting 
in line with legislation, national guidance and APP, while taking on board learning 
opportunities through third sector recommendations, such as the DHR process and 
HMICFRS feedback.     

Devon & Cornwall Police will continue to take a proactive approach to tackling DA, to 
build relationship with and support victims to take police action where appropriate.    

We are acutely aware of the difficult situations occurring where police action is not 
supported by victims.  Our officers will continue to be trained and empowered to 
consider all options available to them to support the safeguarding of those 
individuals, taking account of and balance the Human Rights of those victims 
(specifically where there are no concerns present relating to their capacity to make 
decisions).    

Power of Entry – s17 Police and Criminal Evidence Act 1984 

I am aware this was a key issue considered at inquest.   I have given this matter 
careful consideration and a review of this subject has been undertaken.  

To enhance the knowledge, understanding and confidence of our officers, it is 
proposed there will be further training input for all police officers on use of their s17 
powers.  This will specifically include consideration of the risks associated with DA 
and the importance of assessing this risk when considering the use of s17 powers, in 
line with national guidance and taking into account case law (such as Syed v 
Director of Public Prosecutions 2010).   

To seek to apply a different threshold to cases where there are associated DA 
concerns to the threshold provided for in law, would require a national conversation 
where the parameters of the legislation under s17 PACE and associated national 
guidance can be fully considered and national guidance provided to all Police forces.     

Recognising, however, that there are opportunities for learning which support 
tackling of DA in such circumstances, the following steps are being taken: 

 
 
 
 
 
 
 
 
 
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• 

Implementation of a refresher course for all police officers on the use of police 
powers under s17 PACE.  This is with the aim of specific awareness of risks 
associated with cases of DA.  Conversations with our Learning and 
Development Department are already underway with a view to rolling out an 
appropriate provision in 2025.  

•  Force-wide communications to circulate appropriate learning to all relevant 

officers and staff.  To include reiterating the availability of supervisory support 
for response officers. 

•  Circulation of learning arising from this coronial process to all Superintendents 

to ensure consistency of understanding of safeguarding processes with 
partner agencies.  

Offender Management 

At paragraph 308 of the judgement, I note the suggestion of potential for reflection 
on the issue of facilitating residential placements for offenders requesting alcohol 
detox.  

As expressed in evidence and recorded in the judgement, there are specific 
considerations associated with the appropriate allocation of residential placements 
for detox and there are limited resources in Cornwall and outside of the control of 
Devon & Cornwall Police.  However, our officers and staff within the Integrated 
Offender Management team will continue to explore these options for appropriate 
individuals. 

The Emergency Response 

A full review of the matters relating to the emergency response has been 
undertaken. In addition to the evidence given during inquest, I hope to provide 
further reassurance in this regard.  

In relation to communications with Crimestoppers:  Crimestoppers have the control 
room supervisor’s telephone numbers for Exeter and Plymouth.  This should enable 
them to contact a supervisor or the sergeant on duty in the control room where 
required.   It has also been communicated to Crimestoppers that, in an emergency; 
they should dial 999.    In addition, to enhance working arrangements, 
Crimestoppers have access to the ‘partners page’ on the Single Online Home (SOH) 
site, and regularly send intelligence and information through to our intelligence 
department.   The control room supervisors confirm they regularly take calls from 
Crimestoppers during late and night shifts which indicates that the lines of 
communication are operational on a day-to-day basis.   Recognising the issues in 
this case, we have through ongoing partnership work emphasized the importance of 
using 999 for emergency calls to ensure professionals know when to use this 
number. 

Learning has been recognised and acted upon in relation to the time taken to 
dispatch police units on 31 May 2021 in this case.    

To enhance police response, we are delivering additional training to all CMCU staff 
on what constitutes an immediate and prompt call, including examples and defining 

 
 
 
 
 
 
 
 
 
  
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the criteria and risk level, and the importance of identifying and tasking an 
appropriate resource and showing them as on route, as is policy for all immediate 
calls.   Further refresher training will continue as part of the rolling training delivery 
requirements for the control room.  

Following dispatch of units, the control room will monitor the response where 
capacity allows, tracking the unit to the incident.   Where any concerns are held, 
these are raised with commanders who work closely with the relevant response 
areas.    Working practices remain under review to establish where further 
enhancements can be made.   

For example, there will be introduced a ‘code 5 timer’ which will require after a 
certain period, e.g. 15 mins into an immediate response, there will be a check of 
progress and challenge to the unit as to their attendance time.  It is intended this will 
be in place by the end of May 2024 and written into the deployment policy. 

Paragraph 316 of the judgement raises labelling omissions and failures to bring the 
call-in question to the attention of relevant supervisors in the Command and Control 
Unit.  I can confirm that the current policy directs that anything domestic related is 
brough to the attention of the Command and Control Sergeant.  The Sergeant 
reviews the log to ensure the correct response. The Control Incident Manager (CIM) 
should also be notified of every domestic incident, this is in existing policy, despite 
the grading/risk. In the case of an ‘immediate’ and a ‘prompt’ response (not domestic 
related), the duty response sergeant is not always notified, however, they will be 
monitoring the airwaves radio to oversee what calls their units are going to. If it is a 
vulnerable/routine domestic incident, policy directs the Sergeant is notified that a 
domestic incident has gone onto the ‘routine hatpeg’. 

Paragraph 317 raises the issue of proactively managing domestic incidents.  I hope 
to reassure you that Devon & Cornwall Police have enhanced the proactive 
response in terms of domestic incidents.   For example, the RVR process described 
under ‘New Opportunities’ above, will improve the level of service provided to a 
victim of DA at first point of contact.   

Devon & Cornwall Police also have a new ‘priority vulnerable’ grading for domestic 
incidents which gives them a higher priority, and an ‘SLA 6 hours’ dispatch.  This 
means that our control room Sergeants review and assess DA logs where set criteria 
is met (ones which don't require an immediate response but do carry a level of risk 
or vulnerability associated) and these are graded as 'priority vulnerable'.  This means 
they are held in the control room and given a higher priority for dispatch (within 6hrs).   
Prior to the implementation of this, many of these incidents would have been graded 
as 'routine' and our response would have been slower as the SLA is 24hrs.  

Both measures set out above have enabled us to provide a better, more responsive, 
service to victims of DA.   In circumstances where there is a lack of available units, 
this is escalated to the Sergeant or CIM as per existing policy.  

To mitigate any risk associated with patrol Sergeant resourcing, the control room 
monitor all held incidents and manage the associated risk.  They will review a log if 

 
 
 
 
 
 
 
 
 
 
 
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there are no units on the ground to do so to support decision making of allocated 
units.  

Paragraph 319 explores the concern that a belief is held by response officers that 
logs are actively reviewed by control room supervisors, which is not the case.  I can 
confirm that further communications to all response officer is being delivered to 
confirm that this responsibility resets with the CIM and response Sergeants.  

Finally, since this incident we have introduced a new auto transfer process where 
our resource and incident management officer (RIMO) receive within a shorter period 
of time.  In addition, with the embedded guidance (deployment policy) that there 
should be  deployment of resources with minimal information, the time taken for the 
dispatching of a unit would be reduced, should a similar incident occur now.  The 
command and control target is 5 mins, and regularly achieve 4 mins.   The control 
room are then reliant on the response unit getting there within the response time, 
where possible in all the circumstances.  

I hope the contents of this letter serve to offer reassurance that the issues raised 
within this inquest and recorded within the Judgement dated 22 March 2024 have 
been the subject of careful consideration by Devon & Cornwall Police.    

We will continue to work to enhance the service provided, working with our partner 
agencies, to safeguard and protect victims of domestic abuse.  

Yours sincerely 

Temporary Assistant Chief Constable 
Crime, Justice and Vulnerability

Director General of Operations 
HM Prison and Probation Service 
8th  Floor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

HM Senior Coroner Andrew J Cox 
Cornwall Coroner's Court 
The New Lodge 
Newquay Road 
Penmount 
Truro TR4 9AA 

Dear Sir, 

Inquest Touching the Death of Michaela Anne Hall 

10th  June 2024 

Thank you for your Regulation 28 Report of 27th  March 2024, following the Inquest into the death 
of Michaela Hall. You kindly extended the time for the issue of this response to the 8th  June 2024. 

I know that you will share a copy of this response with Michaela Hall’s family, and I would like to 
take this opportunity to express my condolences for their loss. 

In your Report, you raised the following concerns specifically in relation to the Probation Service 

The  practice  of  PSOs  (or  probation  staff  generally)  self-allocating  files  to  themselves,  in 
particular,  where  they  are  under-qualified  and  insufficiently  experienced  to  do  the  work 
required.  You  may  feel  an  express  policy  provision  mandating  that  managers  allocate 
files/reports is required. 

Probation  Instruction  PI  04/2016  Determining  Pre-Sentence  Reports  (last  updated  12th  January 
2024)  includes  at  para  1.21  that  Probation  Service  managers  must  ensure  that  the  delivery  of 
pre-sentence  reports  (‘PSRs’)  is  undertaken  by  staff  with  suitable  qualifications  and/or  levels  of 
competence in line with the Probation Professional Register Interim Policy Framework (re-issued 
28th  March 2024). 

To  support  the  allocation  process  in  the  future,  a  new  guidance  document  has  been  created 
which  clarifies  when  Probation  Officers  (POs)  or  Probation  Services  Officers  (PSOs)  should  be 
allocated  to  prepare  a  pre-sentence  report  and  this  guidance  is  currently  out  for  consultation, 
prior to publication. This guidance will provide greater clarity on the types of pre-sentence reports 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 which  are,  subject  to manager  discretion,  appropriate for  preparation  by PO  and PSO  grades.  It 
aims  to  ensure  that  Probation  court  staff  can  confidently  understand  when  they  may  undertake 
the  preparation  of  a pre-sentence report dependent  on their grade and the circumstances of the 
case. 

A need to ensure that domestic abuse cases are allocated to officers with the appropriate 
expertise; 

Probation Instruction PI 05/2014 sets  out  the basis for  Case Allocation  and is now supported  by 
supplementary Guidance on the Case Allocation Process. 

A  new  digital tool has now been  implemented  that  enables  a streamlined  approach  to  allocation 
notifications and recording from courts for community cases. The tool provides information on the 
case  for  allocation,  including  risk  of  serious  harm,  risk  of  reoffending  and  risk  registrations,  and 
individual  workloads  to  support  the  Senior  Probation  Officer  making  an  informed  and  defensible 
allocation  decision.  As  the  information  and the  allocation  activity  are  completed  within  the  same 
tool,  this  requires  access  to  fewer  separate  systems  making  it  simpler  to  access/find  the 
necessary information. 

The  completion  of  OASys  risk  assessments  and  SARAs  contrary  to  relevant  guidance  – 
you may feel this reflects a training issue; 

We have reviewed the current Risk and OASys training material, including Spousal Assault Risk 
Assessments  (‘SARA’s)  which  has  been  re-developed  into  a  blended  learning  product  for  new 
entrants.  This  strengthens  the  existing  face-to-face  component  and  provides  a  suite  of  digital 
resources  focused  upon  the  fundamental  principles  of  risk  assessment  and  management 
practice. This new product was launched from March 2023 and the suite of digital resources are 
available  to  all  learners,  to  visit  and  revisit  as  and  when  required.  All  PQIPs  (those  training  to 
become  Probation  Officers)  and  new  entrant  PSOs  are  mandated  to  complete  this  learning  and 
this  is  assured  through  management  oversight  of  the  competency  based  framework  that 
underpins development and pay progression. 

We  have  also  launched  a  new  safeguarding  and  domestic  abuse  blended  learning  package, 
incorporating a a live training event delivered virtually,  providing reflective practice opportunities, 
digital  tools  and  accessible  learning  resources.  These  are  available  at  the  point  of  need,  to 
embed  practice  and  improve  performance  outcomes.  Every  PQIP  completes  the  new  blended 
learning  package  following  completion  of  the  mandatory  Safeguarding  e-learning  and  Domestic 
Abuse e-learning,  which is a requirement for  all Probation  Service staff. The Domestic Abuse e-
learning  has  been  updated  to  reflect  the  latest  e-learning  techniques  as  well  as  up  to  date 
evidence on domestic abuse. 

A  national  rollout  plan  has  ensured  learning  placements  are  prioritised  and  based  on  role  and 
identified  need,  with  training  having  commenced  in  April  2022.  PQIP  learners  and  new  entrant 
PSOs have been prioritised, and all staff are to have completed the new training package by April 
2025. 

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 Within  the  South  West  Region  specifically,  a  rolling  package  of  training  for  practitioners  is 
currently being delivered which includes: 

- Assess Confidently and Manage Effectively; 
- Completion of OASys Sections 1-13 (which identifies factors linked to offending); 
- OASys Risk of Serious Harm assessment/Risk Management Planning; 
- OASys Sentence Planning; 
- Professional Curiosity Harnessing Professional Judgement; 
-
- Quality Management for Senior POs. 

Touch Points Model for Senior POs; and 

Monthly  Protected  Development  Days  have  also  been  introduced  across  the  Region  since 
January  2023.  These  development  days  provide  protected  time  during  which  staff  are  expected 
and encouraged to complete mandatory training and/or other identified learning and development 
activities, including those detailed above. 

Whether 15 days for completion of a comprehensive risk assessment is too long where, in 
a  domestic  abuse setting,  with the perpetrator  and  victim  living  together, the level  of  risk 
can change very quickly; 

Risk  assessment  and  management  is  an  ongoing  process  reliant  on  gaining  information  from 
multiple sources and agencies.  There are points where assessment is made using both dynamic 
and  actuarial  tools.  OASys  includes  a  sentence  plan  that  can  only  be  finalised  once  particular 
elements are  in  place  or  referrals  completed,  for  example  securing  accommodation  or  receiving 
fuller information from partner agencies.  The OASys assessment is a point of time record of that 
fuller information and does not prevent risk management action from being taken. 

OASys  and  Risk  of  Harm  Guidance  provides  staff  with  an  understanding  of  risk  escalation  and 
the  need  to  be  alert  to  change,  responding  swiftly. 
It  is  important  relevant  assessments  are 
updated  accordingly,  however  this  may  follow  the  required  management  actions  being 
undertaken.  Adherence  to  such  practice  is  monitored  through  management  oversight  of  cases 
which in further detailed in guidance. 

A risk assessment takes place when writing a pre-sentence report (and in the absence of a PSR 
an  allocation  risk  assessment  is  completed).  Historically,  a  shorter  period  of  time  for  completion 
of  a  comprehensive  risk  assessment  was  not  achievable  and  compromised  the  fullness  of 
information on which it was based. In light of the concerns you have raised in your Report, this is 
something that will be considered as part of the development of a replacement to OASys which is 
currently taking place. 

A  need  effectively  to  ‘join  up’  probation  with  other  agencies.  It  was  noteworthy  here  that 
probation was represented at MARAC (by definition, meaning the victim was considered to 
be high risk)  yet  both the OASys risk assessment and SARA  assessed  the perpetrator as 
medium risk – a contradiction that you may feel should have been apparent immediately; 

The Probation Service recognises the need to work closely with other agencies in order to share 
relevant  information  and  work  collaboratively  to  effectively  manage  the  risk  posed.  We  routinely 

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 engage with Multi Agency Risk Assessment Conference (‘MARAC’) panels, whose focus is upon 
the  perspective  and  protection  of  the  victim.  Because  of  this,  the  assessment  tools  and  risk 
definitions used to calculate risk differs from those used by the Probation Service, so on occasion 
the  risk  level  outcomes  may  vary,  particularly  if  risk  reducing  restrictions  to  limit  the  perpetrator 
re-offending are in place. That said, it would be reasonable to expect that where risk to a victim is 
identified  as  high  this  would  be  mirrored  in  the  OASys  and  SARA  or  clarity  provided  as  to  the 
relevant difference. 

It  is  acknowledged,  however,  that  the  development  and  maintenance  of  these  close  working 
relationships  with  other  agencies,  including  information  sharing  arrangements,  is  of  paramount 
importance  and  careful  consideration  is  now  being  given  to  how  this  can  be  improved.  We  will 
continue  to  work  to  enhance  the  service  provided,  working  with  our  partner  agencies,  to 
safeguard and protect victims of domestic abuse. 

Thank  you  again  for  bringing  your  concerns  to  my  attention.  I  trust  that  this  response  provides 
assurance that action is being taken to address these matters. 

Yours sincerely, 

Chief Probation Officer 

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