Prevention of Future Deaths reports · 2024

Nicola Forster

Regulation 28 report to prevent future deaths, reference 2024-0334, written 20 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report20 Jun 2024
Reference2024-0334
DeceasedNicola Forster
CoronerEmma Whitting
Coroner areaBedfordshire and Luton
CategorySuicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO: 

1  Commissioner 

1  CORONER 

I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton 
Coroner Service 

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 12 October 2022 I commenced an investigation into the death of Nicola FORSTER aged 45. 
The investigation concluded at the end of the Inquest on 03 June 2024.  The Conclusion of 
the Inquest was that: 

The Deceased intentionally took her own life following a deterioration in her mental 
health which was exacerbated by the actions of her employer. 

4  CIRCUMSTANCES OF THE DEATH 

The Deceased, a serving Metropolitan Police Service (MPS) Sergeant, had worked for the MPS 
for over twenty-two and a half years mostly as a front-line officer; in early 2020, she had 
joined the Learning and Development Team at Hendon as a Public & Personal Safety 
Instructor Sergeant, which was a job she loved. She had struggled with mental and physical 
health issues for several years, including work-related PTSD, but had found counselling helpful 
for dealing with this. Her mental health declined from autumn 2021 when she found herself 
under increasing pressure at work and lost access to counselling. An Occupational Health 
Referral was discussed with her line manager but was not progressed until 23 May 2022 
when, because her health had impacted on her ability to lead and supervise her Team, she 
was also issued with informal management action. Although she was always open about her 
mental health issues, line management decisions made in respect of her reflected a focus on 
managing upwards and were supported by the Senior Leadership Team; these decisions were 
at the expense of the Deceased’s personal and occupational welfare and contributed to a 
further significant deterioration in her mental health. Despite the intervention of the 
Deceased’s local mental health Crisis Team, who provided her with out-patient care from 21 
September 2022, on the morning of 28 September 2022, she was found hanging by a ligature 
made from her dressing gown belt attached to the landing banisters at her home. Emergency 
Services attended but her death was confirmed by paramedics at 10.56 hours.  She had last 
been heard from at around 01.00 hours that morning when she had sent a text message to 
her partner saying that her sleeping medication was not working. 

5  CORONER’S CONCERNS 

During the course of the investigation my inquiries revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken.  In the 
circumstances it is my statutory duty to report to you. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

Although I was informed during the Inquest process about various changes that have been 
made to MPS Employment Policy and Processes since Nikki's death, including the introduction 
of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture 
of poor management and institutional defensiveness, as highlighted in the Baroness Casey 
Review, which these changes do not address.  There is no point in encouraging concerns to be 
raised whilst this culture persists. 

My investiation into Nikki’s death revealed clear evidence of officers, particularly the more 
junior ranking officers, having a fear of speaking out about their management and also an 
unwillingness, by the L&D Senior Management Team, to listen independently to the concerns 
raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your 
representation at the Inquest) appeared only to seek to support the role of senior 
management; even though the Inquest found that aspects of Nikki’s management had been 
seriously deficient and had contributed to her death.  This appeared to me to confirm the 
criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has 
occurred”  and their “systems support wrongdoers”. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or your 
organisation) have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by August 15, 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 

 (Associate Legal Director ELFT) 

I have also sent it to 

Mayor of London 

who may find it useful or of interest. 

I am also under a duty to send a copy of your response to the Chief Coroner and all interested 
persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it useful or of 
interest. 

The Chief Coroner may publish either or both in a complete or redacted or summary form.  He 
may send a copy of this report to any person who he believes may find it useful or of interest. 

You may make representations to me, the coroner, at the time of your response about the 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 release or the publication of your response by the Chief Coroner. 

9  Dated: 20/06/2024 

Emma WHITTING 
Senior Coroner for 
Bedfordshire and Luton Coroner Service 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

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.

Response from Metropolitan Police (PDF)
Our Ref: 

Senior Coroner Emma Whitting 
The Court House  
Woburn Street 
Ampthill 
Bedfordshire 
MK45 2HX 

Dear Mrs Whitting,  

Deputy Assistant Commissioner 
Metropolitan Police Service 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email: 

14 August 2024 

I am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (“MPS”).  On 

behalf  of  the  Commissioner  of  Police  of  the  Metropolis,  I  write  to  provide  the  response  to  the  matters  of 

concern addressed to the MPS in your Report to Prevent Future Deaths dated 20 June 2024. 

On behalf of the MPS, may I first express my sincere condolences to the family and friends of Nicola Forster; 

our thoughts and sympathies are very much with them. 

On 23 May 2024, the MPS wrote to address you on a number of matters.  The MPS has acknowledged and 

reviewed all the matters of concern raised in your Regulation 28 report and responds as follows. 

The Coroner’s “Matters of Concern” 

“Although I was informed during the Inquest process about various changes that have been made to MPS 

Employment Policy and Processes since Nikki’s death, including the introduction of a new ‘Raising Concerns’ 

Policy  in  May  2023,  I  believe  there  remains  evidence  of  a  culture  of  poor  management  and  institutional 

defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no 

point in encouraging concerns to be raised whilst this culture persists. 

My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking 

officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior 

Management Team, to listen independently to the concerns raised.  Furthermore the PSU (as well as the DPS 

investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the 

role  of  senior  management;  even  though  the  Inquest  found  that  aspects  of  Nikki’s  management  had  been 

seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems 

support wrongdoers”. 

MPS Response 

The Commissioner has been clear since his appointment of his expectations and the need for the MPS to not 

be defensive. An approach that the Commissioner, Management Board and the wider MPS seeks to reflect 

through our principles about how we make our decisions, and our values about how we behave. The New Met 

for London plan sets out that the Commissioner and the MPS want to build a culture in the MPS which is open, 

honest and works closely with external organisations and the public to deliver our services with communities. 

Under the Commissioner, we have refreshed and introduced new values and operating principles, which we 

continue to embed across the organisation. We seek to put communities first, be frontline focused, inclusive, 

collaborative and precise; and being accountable is one of our core values. 

We are doing more to learn from external partners, other police forces, reviews and inspections. For example, 

last year the Commissioner and the senior team led a series of 32 borough events, which saw the MPS senior 

management team out in every London Borough to talk about the issues affecting them and the New Met for 

London plan. 

As set out in the letter from the MPS dated 23 May 2024, the MPS introduced a new “Raising Concerns” 

policy regarding the reporting of wrongdoing within the MPS. The new policy, introduced in May 2023, is 

directly focussed on supporting officers and staff who may have a concern about a colleague. Changes include:-  

•  An expanded scope of the previous whistleblowing policy, to include anyone who raises any concern 

to anyone within the organisation,  

• 

Improved guidance on how to report different concerns,  

•  The provision of clearer responsibilities for line managers in relation to the actions they must take 

whenever a concern is reported to them, and  

•  Sets out MPS expectations that everyone who raises a concern, in good faith, will be listened to and 

supported. 

One of the main aims is that where an officer has a concern similar to those which were being expressed by 

PS Forster to her friends and family, or where her colleagues have such concerns, they can be confident they 

will be listened to and supported. 

Whilst staff are encouraged and supported to report concerns openly in person, there are a number of ways a 

report can be made, including via anonymised telephone and online reporting.  To ensure individuals have the 

flexibility to choose the most appropriate method of reporting for them. In November 2022, the MPS was the 

 
 
 
 
 
 
 
 first force in the UK to launch a public facing reporting service for complaints and conduct, in partnership with 

Crimestoppers.    By  March  2024,  the  hotline  has  received  nearly  3,000  reports;  leading  to  over  700 

investigations. 

The MPS recognises that changes to policy and practice alone, will not change culture within the MPS.  The 

MPS has a dedicated Assistant Commissioner and Deputy Assistant Commissioner for Trust and Legitimacy, 

and established a Culture programme as part of the New Met for London commitments, focused on driving 

the culture changes we recognise are needed across the organisation. The Culture programme seeks to build 

staff confidence to speak up and raise concerns, and for managers and leaders to listen and respond.  Activity 

includes: 

•  The development of the new MPS values and their use in our people focused policies and processes; 

such as recruitment, performance management and promotions. 

•  The launch of the Upstander programme: designed to improve the confidence and capability of staff 

to  challenge  behaviours  that  are  inappropriate  and  not  aligned  with  our  values.    The  Upstander 

programme is also designed to increase the understanding and capabilities of leaders to support staff 

and resolve issues. 

The Culture programme is a critical delivery priority for the MPS. It is supported by the creation of a new 

directorate  to  drive  transformation  and  improvements  in  response  to  the  findings  of  external  reviews  and 

inspections of the MPS, and our commitments within the New Met for London strategy.  

Effective  leadership  and  helping  employees  perform  to  the  best  of  their  abilities  is  a  central  role  of  line 

managers. Employees need to understand what is expected of them and be effectively led and managed, so that 

they are motivated, have the skills, resources and support that they need to succeed and be accountable for 

their work.  As you are aware policing is a complex and demanding environment where the public rightly 

expect effective policing and high standards.  We ask our line managers to do very difficult roles to lead and 

properly manage the performance of their staff, alongside what can be complex individual welfare needs - all 

set against the demands of delivering policing for London.  

In this case, the actions of the individual line manager were investigated and we are satisfied that she worked 

hard to find the right balance of performance management and welfare support in this case.   The MPS is of 

the view that the learning here is at an organisational level, rather than for the individual.  The MPS accepts 

that there should have been better supporting infrastructure in place to support Nicola and her line manager.  

This is something that we continuously review.   We continue to undertake significant work to improve both 

our performance management processes (a two way process between the line manager and the individual), and 

how we develop the skills of managers and others to support colleagues who are going through professional 

and / or personal challenges, as outlined in our post inquest written submission to you. 

 
 
 
 
 
 In April 2023, the MPS introduced new leadership training for all first line leaders. This is mandatory and 

equates to between 3 and 8 days of training depending on the role being performed.  A dedicated module 

focused upon trauma and wellbeing is included within this new leadership programme. Between April 2023 

and April 2024, c6200 leaders across the MPS have completed this training. Based on a 98% course feedback 

response rate, 93% said they found the course valuable and would recommend to colleagues. Informal weekly 

feedback  from  course  facilitators  consistently  highlighted  trauma  and  wellbeing  as  a  priority  theme  that 

delegates found valuable. 

Year 2 of the First Line Leaders’ leadership programme launched in April 2024. Responding to staff feedback, 

there is an updated focus on trauma and wellbeing with scenario and discussion based learning. Sessions have 

clear learning outcomes, including role modelling behaviours that foster wellbeing, and signposting access to 

wellbeing support and referral mechanisms.  Delegates can arrange for additional Trauma Impact Prevention 

Techniques Training for their teams; a preventative technique designed by Police Care UK in conjunction with 

Cambridge University that has been developed specifically for (and with) the Police, given the high levels of 

trauma  exposure  for  police  officers.    From  March  2024,  new  leadership  training  programmes  have  also 

commenced for senior leaders, which includes content on trauma and wellbeing. 

The MPS is also investing in new People & Performance Improvement Teams for every front line command 

unit, embedding HR expertise locally to assist line managers with more complex HR issues. This will ensure 

the appropriate support is in place for our employees and their line managers.  We have rolled out ten of 18 

PPIT teams from January 2024, with the further eight team recruitment in progress and expected to be in place 

between August and October 2024. Whilst early stages, we are already seeing an impact for local leaders and 

line managers. 

Alongside broader cultural reforms across the MPS set out in a New Met for London, specific changes have 

been implemented within Learning and Development (“L&D”) over the past 12 months.  These have focused 

on creating a positive and supportive culture for all colleagues working within L&D. Significantly, this has 

included  a  number  of  changes  to  the  L&D  Senior  Leadership  Team,  bringing  in  experience  of  delivering 

cultural reform from elsewhere in the MPS and outside of the policing, strengthened supervision and greater 

levels of oversight with regards to supporting the wellbeing of colleagues across L&D. 

Investment in a new L&D People Strategy in 2023 was in direct response to staff feedback from the 2022 staff 

survey and aims to makes a positive difference for those working in L&D, as well as fostering a culture of 

trust.  Significant improvements include a more structured, co-ordinated and comprehensive programme of 

wellbeing  and  welfare  support  for  L&D  staff;  recognition  for  those  staff  who  go  ‘above  and  beyond’  in 

embodying the MPS’s guiding principles and values; visible Senior Leadership Team engagement across all 

teams  and  locations;  and  an  increased  focus  in  identifying  common  themes  with  regards  to  professional 

standards and culture which are overseen by the Director L&D. 

 
 
 
  
 Looking ahead, L&D are in the process of creating a new strategy and performance function. To inform this 

work senior leaders are actively seeking colleagues’ inputs and suggestions on what more leaders can do to 

better support colleagues. 

As part of our reform of the MPS, to identify and respond to individual and organisational learning, we have 

invested  resources  and  are  transforming  our  approach  to  ensure  high  standards.    The  MPS  Directorate  of 

Professional Standards (DPS) investigation that followed Nicola Forster’s death commenced when information 

was received from a former police officer that Nicola had been bullied.  In accordance with the regulatory 

framework, the conduct allegation was recorded and investigated by the DPS Discrimination Investigation 

Unit, which specialises in matters of discrimination and bullying.  The requirements and purpose of such a 

conduct investigation are set out within regulations and statutory guidance. 

The investigation was independent of L&D, and did not seek to support the leaders within L&D.  In accordance 

with  the  statutory  regulations,  once  the  investigation  was  completed,  it  was  considered  by  an  independent 

Appropriate Authority, who reviewed the evidence and concluded that the line manager had no case to answer 

for misconduct, as defined in the Police (Conduct) Regulations.  

Whilst there was no finding of conduct, the DPS investigation did identify that improvements should be made 

to the way line managers transferred staff when changing roles, and for leaders to have appropriate access to 

officer/staff personal circumstances in order that they have the information necessary to support individuals. I 

understand  evidence  was  read  at  inquest  which  provided  detail  of  a  new  functionality  within  the  MPS 

performance  and  development  system  that  enables  new  line  managers  to  have  a  greater  awareness  of  an 

individual’s history. 

At inquest, the Commissioner was represented by the Directorate of Legal Services (“DLS”).  Nicola Forster’s 

line manager was separately legally represented as she was given Interested Person status at inquest.  All police 

witnesses, except one individual, who gave evidence at inquest were supported by the MPS.  You will be aware 

that some witnesses gave frank and often critical evidence about the MPS, this did not change the support they 

were provided. 

Current and former police officers and staff called as witnesses to an inquest, where the Commissioner is an 

Interested Party, are provided with support.  This includes: 

•  Provision of relevant documents; 

•  Assistance with the preparation of any statement; 

•  A point of contact for officer/staff to ask any questions they have about the inquest process; 

•  Case conference with DLS and MPS counsel, to assist the witness’s understanding the nature of an 

inquest, their role as witnesses and to assist them with any questions they have. 

 
 
 
 
 
 
 At all times, it is made clear to officers and staff that they are the Coroner’s witness, not the Commissioner’s 

witness, and their evidence is their own.  The MPS also has a dedicated team within its Inquiry & Review 

Support Command (IRSC), who provide operational and practical support to police officers and staff who give 

evidence at inquests, where the Commissioner is an interested party.  This inquest team provide a single point 

of contact for witnesses, both prior to and during inquest proceedings.  

The  IRSC  also  work  closely  with  DLS  to  review  inquest  outcomes  for  both  case  specific  learning  and  to 

identify themes that arise through analysis of different inquest proceeding.  The MPS has introduced guidance 

for managers following the death of a colleague and a chief officer provides additional oversight of all inquest 

proceedings, where it is considered that workplace relationships may be a potential factor.  This is improving 

how  the  MPS  seeks  to  learn  and  ensure  that  any  identified  improvements  are  shared  through  wider 

organisational learning, for example changes to leadership training and wellbeing support. 

The Commissioner and the MPS are committed to making the improvements we recognise are needed in our 

culture to become less defensive, as reflected through our principles about how we make our decisions, and 

our values about how we behave.  I hope this response provides you with an appropriate level of assurance in 

relation to that commitment. 

Please do not hesitate to contact me should you require any additional information or clarification regarding 

the above. 

Yours sincerely

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