Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0414, written 23 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jul 2024 |
|---|---|
| Reference | 2024-0414 |
| Deceased | Neil Woodley |
| Coroner | Jonathan Landau |
| Coroner area | South London |
| Category | Suicide (from 2015) |
| 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. Surrey Police 2. Metropolitan Police Service 1 CORONER I am Jonathan Landau, assistant coroner for the coroner area of South London 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 11 March 2024 an investigation was commenced into the death of Neil John Woodley. The investigation concluded at the end of the inquest on 17 July 2024. The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH Neil Woodley was found suicide notes suggest he killed himself some time overnight. at 7.25 am on 4 January 2024. Evidence from 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. – Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police. On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations 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 17 September 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 am 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 other person who I believe may find it useful or of interest. In this case, I have sent it to Mr Woodley’s brother. 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 Jonathan Landau, HM Assistant Coroner 23 July 2024 2
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.
Our Ref: Your Ref: HM Assistant Coroner Jonathan Landau Croydon Coroners Court and Offices 2 Davis House Robert Street Croydon London CR0 1QQ Director Command and Control Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A 2JL 4th September 2024 Dear Mr Landau, I am the Director for Command and Control in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matter of concern addressed to the MPS in your Report to Prevent Future Deaths dated 23rd July 2024. On behalf of the MPS, may I first of all express my sincere condolences to the family and friends of Mr Neil John Woodley, our thoughts and sympathies are very much with them. The Coroner’s “Matter of Concern” The Prevention of Future Deaths report dated 23rd July 2024 records:- ‘Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police. On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases.’ MPS Response On 4th January 2024 at 7.48am, a member of the public called Surrey Police (SPS) informing them that a male was found hanging in the woodlands behind the Fox Public House, Caterham. SPS correctly passed the call to the MPS and officers attended in partnership with the London Ambulance Service (LAS) and the London Fire Brigade (LFB). The person found hanging and deceased was identified as Mr Neil John Woodley. The attending MPS officers identified Mr Woodley’s home address and attended the location. MPS policy states that when MPS officers attend an alternative venue/location to the original location (recorded on the Computer Aided Despatch [CAD]), a new CAD is to be created. The new CAD is then linked to the original CAD and assigned to the officers attending. This ensures that officer locations are known for safety reasons and if further calls are received incidents can be effectively managed. Unfortunately, on this occasion a linked CAD was not created. The MPS have no records of Mr Woodley’s work colleague or SPS contacting the MPS regarding an incident concerning Mr Woodley on 4th January 2024. The MPS Command and Control (MetCC) however have three records regarding Mr Woodley’s home address, the LAS and SPS on 5th January 2024. On 5th January 2024 at 10.25am, SPS passed a call to the MPS which the MPS call handler processed correctly and created a CAD reference 2062/05JAN24. However, due to a new CAD not being created when officers attended Mr Woodley’s home address on 4th January 2024 this was not linked to the initial incident and therefore the operator was unaware that Mr Woodley had already been found deceased. CAD 2062/05JAN24 was passed to the LAS by the MPS under the Right Care Right Person (RCRP) Policy as a welfare check and was subsequently closed by Met CC as LAS were now dealing. This was the correct decision and in line with MPS policy. LAS attended Mr Woodley’s home address unaware of the events the day before. In regards to a failure of communication between SPS and MPS, we do not believe this occurred as no record of a call to the MPS on the 4th January 2024 can be located. As an organisation, learning will be delivered to MPS staff and officers, highlighting the importance of strict location sharing and compliance with standard operating procedures designed to protect front line policing and prevent correlation errors such as this incident. I trust this provides the reassurance that the MPS has considered the matter of concern you have raised. Yours sincerely,
Tim De Meyer Chief Constable 16 July 2025 Dear Mr Landau, INQUEST INTO THE DEATH OF NEIL WOODLEY – PREVENTION OF FUTURE DEATHS I write to provide a response to the Prevention of Future Deaths Report (PFD Report) issued on 23 July 2024 in connection with the inquest into the death of Neil Woodley which took place on 17 July 2024. I would firstly like to extend my sincere apologies for the delay in providing this response. I understand that an email was sent by the Coroner’s Officer to three different email addresses attaching the PFD Report. It would appear that two of these email addresses are not valid email addresses used by Surrey Police. One of the email addresses, for the Contact Centre, does appear to be correct and an internal investigation is underway to establish why it was not escalated in accordance with our usual policies and procedures. I will ensure that appropriate actions are identified and completed to ensure that any communications of this nature are promptly escalated in the future. PFD Report It is understood that evidence was given at the inquest by Mr Woodley’s family members that a call was made to the police on 4 January 2024 by a colleague who was concerned that Mr Woodley had not arrived at work. The following day there was a welfare check conducted by the London Ambulance Service who reported that there was a delay in their attendance due to some confusion between Surrey Police and the Metropolitan Police Service (MPS). Concern was expressed in the PFD Report about the risk of future deaths arising from the failures in communication between the two police forces. Summary of events A review has been undertaken of the records held by Surrey Police of the calls received about Mr Woodley on 4 and 5 January 2024. These records can be summarised as follows (cid:127) 4 January 2024 Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk o 07:46 a CAD was created by Surrey Police in relation to a call from a member of the public who believed that they had discovered a deceased person in woodland. o 07:47 the Surrey Police call handler passed the call to MPS who then attended the scene with the London Ambulance Service and the London Fire Brigade. o 09:09 the CAD was closed. (cid:127) 5 January 2024 o 10:13 a CAD was created by Surrey Police following a report from a colleague of Mr Woodley who was concerned for his welfare after he failed to attend work. o 10:25 a call was placed to MPS who advised that they were sending officers and also calling the informant. o 10:34 the informant was advised that someone from MPS would be contacting them. o 10:57 the CAD was closed. Outcome of the review Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action. I have had the benefit of reviewing the MPS response to the PFD Report dated 4 September 2024. In this letter, the MPS summarises their records of the telephone calls received by them on 4 and 5 January 2024 about Mr Woodley. They conclude that they do not believe there was any failure in communications between Surrey Police and MPS. I would agree with this conclusion having reviewed the records held by Surrey Police. It has not been possible (based on our limited records) to work out why the London Ambulance Service reported a delay in their attendance due to confusion between the two police forces. However, it is noted that the MPS has explained the reasoning behind the CADs for 4 and 5 January 2024 not being linked by their control room which meant that those attending on 5 January were unaware that Mr Woodley had already been found deceased. We trust that this response is of assistance and helps to clarify the records Surrey Police hold about the events of 4 and 5 January 2024. Yours sincerely Chief Constable
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