Jake Girton

Mr Graeme Irvine 
HM Senior Coroner 
Walthamstow Coroners Court 
Queens Road Walthamstow   
London 
E17 8QP 

Deputy Assistant Commissioner 

         Metropolitan Police Service 
          New Scotland Yard 

Victoria Embankment 

            London 
           SW1A 2JL 

Thursday 4th December 2025 

Dear Mr Irvine, 

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

the matters of concern addressed to the Metropolitan Police Service (MPS) in your Report to 

Prevent Future Deaths dated 29th September 2025 following the inquest into the tragic death 

of Mr Jake Hickey Girton. 

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

Mr Girton, our thoughts and sympathies are very much with them. 

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” and the MPS’ Responses 

Matter of Concern 1 

Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer 

who  was  investigating  the  offence for  which  Jake  was  arrested  was  under  an  obligation  to 

inform that complainant (the hospital) of Jake's release from custody. There is no evidence to 

suggest  this  was  done. Evidence  from the  Psychiatric trust  at  inquest  indicates that  on  the 

17th January 2024, they were under the impression that Jake would remain in police custody, 

and had they known he was released, greater efforts may have occurred to support Jake in 

the community. 

 
 
 
 
 
 
 
 
 
 
 
 
                            
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 MPS Response 

The relevant policy and guidance that applies here are the Victims’ Code and the MPS General 

Investigations Policy (GI). 

The Victims’ Code defines a victim as below: 

“Who is a ‘victim’ under this Code? 

This  Code  acknowledges  that  the  terms  ‘complainant’  and  ‘survivor’  are  often  used  in  the 

criminal justice system to describe a person who has made a criminal allegation to the police. 

However, for the purpose of this Code, the definition of a ‘victim’ is: 

•  a  person  who  has  suffered  harm,  including  physical,  mental  or  emotional  harm  or 

economic loss which was directly caused by a criminal offence. 

•  a close relative (or a nominated family spokesperson) of a person whose death was 

directly caused by a criminal offence. 

You can also receive Rights under this Code if you are: 

•  a parent or guardian of the victim if the victim is under 18 years of age or 

•  a nominated family spokesperson if the victim has a mental impairment or has been 

so badly injured because of a criminal offence that they are unable to communicate or 

lacks the capacity to do so. 

The Victims’ Code in this incident applies to the member of staff at Goodmayes Hospital who 

was the alleged victim of assault by Mr Girton. The officer in the case (OIC) informed the victim 

of Mr Girton’s release from custody and VCOP was accordingly complied with.  

Businesses/charities can be victims of crime but the Victims Code is specifically for people 

rather than organisations or institutions. 

The GI provides guidance and actions for all criminal investigations and stipulates actions to 

be taken with regards to victims of crime. The GI Policy is the relevant policy for the hospital. 

The policy in place at the time of death stated: 

‘3.4     Victims  and  witnesses  –  actions  that  must  be  taken  involving  victims  and 

witnesses 

 
 
 
 
 
 
 
 
 
 Every officer MUST follow the requirements set out in the VCOP policy whilst completing the 

actions set out below […] 

3.4.1  Obtain  victim/witness  full  contact  details  including  their  preferred  method  of  contact, 

alternative phone numbers, email addresses […] 

3.4.9     All  contact  and  attempted  contact  with  the  victim  should  be  recorded  on  the  CRIS 

investigation as well as any investigative actions that arise from these communications. 

3.4.10 Provide the victim with a Victim Care Card and explain what will happen next even if 

no further action is to be taken.’ 

The GI Policy states VCOP should be adhered to as well as the outlined actions, highlighting 

them  as  distinctly  different  and  applicable  in  addition.  The  OIC  did  not  separately  inform 

Goodmayes Hospital of Mr Girton’s release from custody in respect of the hospital’s status as 

a victim from the offence of criminal damage. The OIC did however inform the same member 

of staff who was the alleged victim of assault. This victim’s details were present on the CRIS 

report for the criminal damage. The OIC has confirmed that he held a genuine expectation 

that the victim would duly update the hospital records.  

The MPS are currently reviewing the GI policy and propose to include the following section to 

ensure  there  is  clarity  around  the  responsibility  to  provide  updates  to  representatives  of 

businesses and other enterprises:  

‘Businesses or other enterprises such as charities are not included within the definition of a 

victim under the Victims’ Code. However, they can be victims of crime and receive the services 

in  the  Code  and  make  an  impact  statement  where  a  criminal  offence  has  been  committed 

against them, subject to provision of a named point of contact to the relevant service provider. 

For  the  purposes  of  this  policy,  and  in  recognition  of  the  need  for  effective  communication 

during investigations, officers should identify and liaise with the most appropriate named point 

of  contact  within  affected  businesses/organisations  to  provide  relevant  updates.  Where  a 

crime is perpetrated against both an individual (e.g. an employee) and the organisation they 

represent,  officers  must  ensure  that  investigative  updates  are  provided  separately  to  the 

individual victim in accordance with the Victims' Code, and to the organisation via a suitable 

representative.  This  ensures  that  individuals  receive  appropriate  support,  distinct  from  the 

organisation’s interests and obligations.’  

The section above is currently undergoing final approval and is scheduled to be incorporated 

into the policy in 2026. 

 
  
 
 
 
 The MPS acknowledges the Coroner’s concerns regarding the sharing of information between 

police  and  mental  health  services  when  individuals  experiencing  mental  health  crisis  are 

released  from  police  custody.  The  MPS  recognise  the  importance  of  timely  and  effective 

communication to ensure appropriate follow up and reduce the risk of harm.  

A review has already been undertaken in relation to information sharing with Mental Health 

Trusts which has identified a gap in current arrangements. Specifically, there is no consistent 

mechanism to ensure Mental Health services are notified when an individual is released from 

custody. This gap can result in missed opportunities for early intervention and continuity of 

care.  

To address this, the MPS has initiated the following measures: 

1.  The MPS has completed mapping of existing information sharing pathways. This work 

has clarified where current processes fail or rely on ad hoc communication rather than 

a formulised system.  

2.  The  MPS  is  developing  a  protocol,  agreed  through  local  partnership  governance  to 

ensure that when a person identified as being in mental health crisis or having been 

arrested in a mental health setting, is released from custody, relevant information can 

be  shared  promptly  and  lawfully  with  the  appropriate  Mental  Health  Trust  or 

Community  Mental  Health  Team,  if  known.  This  protocol  is  being  aligned  with  data 

protection  and  safeguarding  requirements  under  existing  information  governance 

frameworks. 

3.  The MPS is working with Mental Health Trust Leads and the Joint Mental Health and 

Police  Group  (JMHPG)  to  develop  consistent  arrangements  across  London.  This 

includes  establishing  clear  lines  of  accountability  and  escalation  routes  where 

concerns arise about a person’s welfare post release.  

4.  Additional  guidance  is  being  developed  for  custody  and  investigating  officers, 

supported  by  the  MPS  Mental  Health  Lead.  This  will  reinforce  the  importance  of 

identifying  those  at  risk,  recording  relevant  indicators  and  initiating  the  appropriate 

referral or notification before release.  

 
 
 
 
 
 
 
 The MPS is committed to strengthening partnership working with health services to prevent 

future  deaths  and  ensure  vulnerable  individuals  receive  the  right  care  and  support  at  the 

earliest opportunity. The MPS will continue to monitor progress through the JMHPG.  

Matter of Concern 2 

Despite a Directorate of Professional Standards review, there is no evidence that the MPS 

identified  any  shortcoming  in  their  performance  in  dealing  with  Jake,  consequently  no 

evidence exists of any reflection or remediation of this failing. 

MPS Response 

The  MPS  Directorate  of Professional  Standards (DPS)  conducted a  comprehensive  review 

into this matter as per their remit and standard operating procedure.  It was determined that 

this  incident  did  not meet  the  definition  of  a  Death  or  Serious Injury1  (DSI) following  police 

contact  as  defined  in  the  Independent  Office  for  Police  Conduct  (IOPC)  Statutory 

Guidance.  Upon conducting DSI reviews, the expectation is for DPS to also consider whether 

there  is  an  obvious  conduct  matter,  performance  matter  or  opportunity  for  individual  or 

organisational learning. In this instance, the review did not identify any such learning.   

It  is  noted  in  the  matter  of  concern  that  the  failure  to  update  the  facility  was  a 

conduct/performance/learning  matter  and  that  this  should  have  been  identified  by  the 

DPS.   The  MPS  believe  the  DSI  review  was  appropriate  and  went  as  far  as  would  be 

expected.  

1 A DSI matter means any circumstances (unless the circumstances are or have been the subject of a complaint 
or amount to a conduct matter) in, or as a result of which, a person has died or sustained serious injury and:  
• at the time of death or serious injury the person had been arrested by a person serving with the police and 
had not been released or was otherwise detained in the custody of a person serving with the police; or  
• at or before the time of death or serious injury the person had contact of any kind – whether direct or 
indirect – with a person serving with the police who was acting in the execution of their duties and there is an 
indication that the contact may have caused – whether directly or indirectly – or contributed to the death or 
serious injury. However, this sub-category excludes contact that a person who suffered the death or serious 
injury had whilst they were acting in the execution of their duties as a person serving with the police.  

Section 12, Police Reform Act 2002  

‘Serious injury’ means a fracture, a deep cut, a deep laceration or an injury causing damage to an internal 
organ or the impairment of any bodily function.  

Section 29, Police Reform Act 2002 

 
 
 
 
 
 
 
 
 
 
 Please do not hesitate to contact me should you require further information from the MPS. 

Yours sincerely, 

Deputy Assistant Commissioner 

Metropolitan Police Service 

Professionalism