Prevention of Future Deaths reports · 2024

Martin Stubbs

Regulation 28 report to prevent future deaths, reference 2024-0573, written 25 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report25 Oct 2024
Reference2024-0573
DeceasedMartin Stubbs
CoronerOliver Longstaff
Coroner areaWest Yorkshire (Eastern)
CategoryPolice related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

OFFICE OF THE
SENIOR CORONER
for the County of West Yorkshire
(Eastern District)

His Majesty’s Coroner’s Office
The Coroner’s Courts
Burgage Square
Wakefield WF1 2TS

Telephone: 01924 302180
Email: hmcoroner@wakefield.gov.uk

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS

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

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

    1. Professional Standards Department, West Yorkshire Police, Laburnum Road, Wakefield
         WF1 3QP
    2. Independent Office for Police Conduct (IOPC), PO Box 473, Sale, M33 0BW

CORONER

I am Oliver Robert Longstaff, Area Coroner for the Coroner area of West Yorkshire (Eastern).

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.

INVESTIGATION and INQUEST

On 29/08/2024 I commenced an investigation into the death of Martin Ian Stubbs, aged 50. The
investigation concluded at the end of the Inquest on 24/10/2024. The conclusion of the Inquest
was that Mr Stubbs’ death was a suicide by hanging. He had hanged himself at his home
address on 26/08/2024  and left notes to his family indicative of an intention to end his life. The
medical cause of death was 1a) Hanging.

CIRCUMSTANCES OF THE DEATH

Mr Stubbs was a serving Police Officer. On 29/11/2022, nine days after receiving a long service
and good conduct award at a formal ceremony in Wakefield, he was arrested by officers from
West Yorkshire Police Professional Standards Department and bailed. He was suspended from
duty. He remained suspended and on bail until his death. He had sought medical advice and
assistance because of the mental strain of being suspended for so long, and a note recovered
from the scene stated his belief that West Yorkshire Police had contributed to his death.
CORONER’S CONCERNS

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

The MATTERS OF CONCERN are as follows.  –

Mr Stubbs’ father (a former officer himself and still a civilian police employee) expressed his firm
belief that the length of time he had been suspended from duty had played a significant part in

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 his son’s decision to take his life. It is a concern that someone subject to an internal disciplinary
process has a legitimate expectation that that process will be dealt with expeditiously in the
interests of all parties, and that that legitimate expectation was not met in Mr Stubbs’ case. Mr
Stubbs’ family do not understand whether the delay in concluding the process reflects resource
issues or an institutionalised practice of allowing such matters to drift without proactive
management to bring them to a conclusion. Anecdotally, Mr Stubbs’ family are aware of other
long outstanding internal disciplinary proceedings and fear other families may have to go
through an experience similar to theirs.
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe your organisation
has the power to take such action.
YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely
by 13/12/2024. 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.
COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr

.

I am also under a duty to send the Chief Coroner a copy of your response.

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

You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Signed:

Oliver Longstaff
Area Coroner
West Yorkshire (E)

Date: 25/10/2024

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Responses

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.

Response from Iopc (PDF)
OFFICIAL 

Sent via email to –  

13 December 2024 

Dear Sir 

IOPC response to the PFD issued by the coroner on the Operation Winterville investigation 

I write in response to the Prevent Future Death report dated 25 October 2024, following the Inquest 
into the death of PC Martin Stubbs. We were saddened to learn of the officer’s death and offer our 
condolences to his family and colleagues. We take the welfare of subject officers seriously and 
acknowledge the stress and worry that being under investigation brings. We are committed to 
continue to improve the timeliness of our investigations and that we will engage with forces to 
ensure that subjects receive the support they need. 

The welfare of our service users is of the upmost importance to the IOPC. We encourage staff to 
take action and make the necessary referrals expeditiously, where they become aware of a risk of 
harm to service users. In relation to serving police officers under investigation, their welfare and 
wellbeing is a key consideration for our investigators. Decisions regarding investigative actions 
generally factor in the welfare of the subject officer. However, primary responsibility for welfare 
rests with the officer’s force as they are best placed and equipped to provide the necessary 
support. As a matter of law, decisions on suspension are made by the officer’s force 1and forces 
generally, as was the case here, will appoint a welfare officer to support the officer under 
investigation. 

Before addressing this in more detail, I have set out what guidance the IOPC already has in place 
for its staff on this topic, copies of which are included with this letter: 
- The following pages from our staff Operations Manual2  
o  Aide memoire on threats of suicide and self harm  
o  Arrests and search warrants  
o  Concerns about suicide or self harm  
o  Considerations for the welfare and safeguarding of vulnerable police staff and subjects  
o  Considering family welfare  
o  Considering the needs of ethnic minority police officers and staff subjects  
o  Dealing with threats of suicide and self harm  
o  Force responsibilities  
o 
Initial considerations  
o  Post investigation  
o  Serving a notice  

1 In accordance with Regulation 11(11) of the Police Conduct Regulations 2020 in independent and directed investigations, the IOPC 
is consulted on the decision to suspend an officer and subsequent decisions following reviews of the suspension. 
2 The Operations Manual is an internal site for IOPC staff. It contains all the guidance, templates and documents that are required to 
carry out our operational work 

 
 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

o  Support for IOPC staff  
o  Support organisations available for police staff and their families  
o  What to do if you have a safeguarding concern 

- A welfare strategy template, the idea of which is to act as a prompt and an aide memoire for staff 
undertaking a welfare strategy. We are currently looking at including it (or a version of it) on the 
above page of the Operations Manual. 

As an example, below are some extracts from the Operations Manual attachment (Considerations 
for the welfare and safeguarding of vulnerable police staff and subjects):  

Under Health and Safety Regulations all employers have an obligation to support and safeguard 
their staff, in this case police forces. Section 2.1 of the Health & Safety at Work Act 1974 states:  

“It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, 
safety and welfare at work of all his employees”.  

The Home Office Guidance 2020 (Conduct, Efficiency and Effectiveness: Statutory Guidance on 
Professional Standards, Performance and Integrity in Policing) provides information regarding the 
force responsibilities. Sections 5.51 to 5.57 provide further information (pgs. 50 & 51) but the 
opening statement is: 

“5.51 It is the responsibility of Chief Constables to manage the welfare of officers and staff 
throughout their careers which includes during any investigation, performance concerns and 
misconduct proceedings. This is a duty of care and it remains the role of elected Police and Crime 
Commissioners to ensure they are held to account for this and other duties”. 

Notwithstanding the information already available for staff, the IOPC are aware there is a need for 
more robust organisational guidance on this. This will cover what needs to be done when welfare 
concerns are brought to the IOPC’s attention regarding any of our service users, to ensure that 
those who are best placed to deal with the concerns have all the information they need to properly 
discharge their duty. Our intention is therefore to strengthen the organisational guidance we 
already have in place. 

In the interim, we have circulated an internal communication to all investigative staff, to signpost 
them to the internal guidance already available to them. We have also explained that this guidance 
will be reviewed and may be updated, to focus on the need to improve our processes in this area 
and make it clear what should be done where we come across material suggestive of risk. Staff 
have also been told to seek legal advice and / or advice from our Safeguarding Team if they are 
ever unsure. But in any event and in all circumstances, to provide as much detail as possible to 
those best placed to deal with the concern/s for welfare, and to follow up to obtain confirmation of 
exactly what has been said and done, and escalated appropriately if there are any concerns about 
this. A copy of the communication (dated 7 June 2024) has also been provided with this letter.  

The investigation into the conduct of the subject officer was an extremely complex and sensitive 
investigation, which identified and produced complex various strands of lines of enquiry. 
Predominantly, the vast majority of enquires centred around the identification of adult and child 
witnesses (which produced over 40). 

 
 
 
 
 
 
 
 
 
 
 
 OFFICIAL 

To ensure the professionalism and integrity of the investigation, principles of achieving best 
evidence were adhered to. This generated significant pressures for the investigation, particularly 
around procedural methods, and availability of all those adversely affected in this investigation. 

Significantly, aside from obtaining witness testimonies the investigation also required a 
proportionate, but detailed analysis of digital media platforms across not only Police systems but 
Local Authority ones which were accessed and utilised by the subject officer.  
With only limited resources, the completion of all the lines of enquiry required careful and 
meticulous planning, prioritising those of a sensitive and urgent manner, particularly concentrating 
on the most vulnerable witnesses which was paramount throughout the investigation. 

We have evidence that throughout the investigation the officer’s welfare was discussed between 
ourselves and the force. We were aware that a welfare officer had been appointed and that he was 
receiving support from the Police Federation.  However, as this was a directed investigation, all 
communication with the officer including the interviewing team was conducted by police officers not 
ourselves.  

We take timeliness of our investigations very seriously. We continue to work hard to improve, 
because we know that a slow system does not benefit anyone. Over the past year we have 
completed 83% of independent investigations within 12 months and more than a third in six 
months, rising to 43% in the first six months of this year.  

We are currently undergoing a radical Transformation Programme, which  is focused on improving 
our operational delivery and the service we provide to the public, police and our stakeholders.    
It will drive an increase in our productivity so that we can do more high-quality, timely investigations 
and reviews, and make service-user improvements across the police complaints system. Having 
reviewed the timeline for this particular investigation, we are satisfied that there were clear reasons 
for the length of time the investigation took, albeit we are committed to improving our timeliness, as 
outlined above. 

Yours sincerely 

Regional Director North East 
Independent Office for Police Conduct
Response from West Yorkshire Police (PDF)
Professional Standards Directorate
PO BOX 9
Wakefield
WF1 3QP
Tel:   
Email: 
Website: www.westyorkshire.police.uk

Professional Standards Directorate

Dear Sir,

I write on behalf of the Chief Constable of West Yorkshire Police (WYP) in response to
the Prevent Future Death report dated 25 October 2024 and received by WYP on 11
November 2024.

From the outset, I would like to express my condolences to PC Stubbs’ family and
friends. We take the welfare of our o(cid:431)icers very seriously, in particular when an o(cid:431)icer is 
subject of an ongoing conduct matter.  I have set out below a summary of the
investigation and the steps the force took to provide Martin with support.

On 24 November 2022, the Counter Corruption Unit (CCU) received information, from a
person who initially wished to remain anonymous, about PC Stubbs’ conduct.  On 28
November, an o(cid:431)icer from the CCU met with the person who had provided information 
about PC Stubbs’ conduct.

 On 29 November, PC Stubbs was arrested for the o(cid:431)ence of Misconduct in Public 
O(cid:431)ice. He was interviewed on the same day and was released on conditional bail. Due
to the seriousness of the allegations a decision was made to suspend PC Stubbs from
duty, in line with policy, this decision was reviewed every 28 days by the Deputy Chief
Constable. A Welfare O(cid:431)icer was appointed to provide support to PC Stubbs. Following
his release from custody, the Welfare O(cid:431)icer took PC Stubbs home. Throughout the 
investigation, a Welfare O(cid:431)icer was available to provide support to PC Stubbs. 

 WYP notified the IOPC, who determined that the investigation into PC Stubbs would be
conducted by WYP and overseen by the IOPC, which is called a ‘directed investigation’.
Throughout the investigation, the Investigating O(cid:431)icer (IO) met with, and provided 
updates to, the IOPC.

 The first witness was interviewed on 5 January 2023, this witness identified 2 further
witnesses. The victims identified from the initial reporting, were categorised as
‘vulnerable’ and visual recorded interviews were conducted. During these interviews,

 Victim 1 provided details of a further incident concerning PC Stubbs and from this
account 5 further witnesses were identified.  3 further witnesses were identified from
the account provided by Victim 2. This was a recurring feature of the investigation –
additional witnesses constantly being identified from accounts provided.

On 20 February 2023, PC Stubbs was released under investigation and bail conditions
no longer applied.

 During the investigation, several additional conduct matters concerning PC Stubbs
were identified, which had to be assessed and investigated.

 By 18th March 2024, the IO had provided pre-interview disclosure (198 pages) to PC
Stubbs and his legal representative. 2 days later, further concerns were raised about PC
Stubbs which required further investigation, this investigation concluded on 9th April
2024.

On 22nd April, a voluntary interview was conducted with PC Stubbs and his legal
representative. The Federation Representative was present to provide support. Prior to
the interview, a custody nurse assessed PC Stubbs to ensure that he was fit to interview
and a risk assessment was conducted.

A further voluntary interview was conducted on 26 April and PC Stubbs was due to
attend a further interview on 8 May, however, he was unable to attend this, and the
interview was rearranged for 14 May 2024.

 The final investigation report (138 pages) was submitted to the IOPC on 6 August 2024,
which provided detailed evidence on a total of 22 allegations. During the investigation,
52 individuals were spoken to, and 38 witness statements were obtained. Digital
devices and use of police systems all had to be examined.

On 15 August, the IO informed PC Stubbs’ legal representative that a report had been
submitted to the IOPC and on 26 August, PC Stubbs, sadly took his own life.

 The above chronology (which is a summary only) demonstrates the serious and
complex nature of the investigation. It is acknowledged that any o(cid:431)icer under 
investigation will need support, and this is why each o(cid:431)icer is supported by a trained 
and approved Welfare O(cid:431)icer. A Welfare O(cid:431)icer was appointed on 29th November 2022.
The Police Federation provided support to PC Stubbs and arranged counselling for him.
Risk assessments were conducted by his line manager and adjustments were made to
support PC Stubbs. It is regrettable that the investigation did take 19 months, but it is
important that serious allegations are properly and thoroughly investigated. As set out
above, the decision that PC Stubbs remain suspended was made by a Chief O(cid:431)icer and
reviewed every 28 days.

 Following receipt of your Prevent Future Death Report, WYP has conducted a full review
of the investigation and discussed the concerns you have raised with the IO. To address
the concerns you have raised, WYP has implemented the following changes with
immediate e(cid:431)ect:

The DCI at Professional Standards will review all investigations that have been assessed
as meeting the threshold for gross misconduct every 3 months and assess whether the
investigation has the necessary resources.

The Head of Professional Standards will conduct a review of all investigations that have
been assessed as meeting the threshold for gross misconduct every 12 months to
ensure that the investigation is being conducted promptly and has the necessary
resources.

The senior leadership team at Professional Standards will meet quarterly with senior
leaders at the IOPC to discuss investigations that involve the IOPC, part of the review
will be to ensure that the investigation has the correct resources and the appropriate
welfare provisions are in place.

Yours Sincerely

Detective Chief Superintendent
Director of Professional Standards

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