Aminata Coulibaly

Ms Sonia Hayes  
HM Area Coroner for Essex 
Seax House 
Ground Floor 
Essex County Council 
Victoria Road South 
CM1 1LX 

Chief Superintendent 
Harlow Police Station 
The High 
Essex 
CM20 1HG 
13th January 2026 

Response to Regulation 28 Report to Prevent Future Deaths: Inquest into the death of 

Ms Aminata Coulibaly 

Dear Ma’am, 

I write on behalf of Essex Police in response to your Regulation 28 report to Prevent Future 

Deaths following the inquest touching upon the death of Ms Aminata Coulibaly. This letter 

acknowledges the concerns you have raised and sets out the action already taken alongside 

measures Essex Police will take. 

Your report identified risks which I have summarised into four areas: 

1.  Victim communications and information-sharing: emails sent by Ms Coulibaly on 22nd  

June 2022 and her phone call on 24th June 2022 were not uploaded to the Essex 

Police Athena system or shared with the Essex Partnership University NHS 

Foundation Trust (EPUT). 

2.  Contact Management Command (formally known as Force Control Room (FCR)) 

recording and escalation: Contact Handlers did not consistently record information 

provided by EPUT nor clarify indicators to support THRIVE assessment and 

appropriate deployment. 

3. 

Investigation management standards: the absence of a Case Action Plan, poor 

suspect interviews, deficiencies in hate-crime investigative supervision and victim 

care, contributing to Victims’ Code non-adherence and Ms Coulibaly being incorrectly 

told her case was closed. 

Protecting and serving Essex 
 
 
 
 
 
 
 
 4.  Safeguarding pathways and referrals: interaction between police and health/social 

care services did not consistently translate concern into formal safeguarding referrals 

and coordinated support. 

We accept that the above areas required improvement.  In addition to the evidence provided 

during the inquest hearing, I will detail the action Essex Police has taken since 2022 to 

improve and address your concerns.  

1.  Victim Communications and Information-Sharing 

Essex Police places great importance on the service we provide to all victims, especially 

those who are vulnerable, and this is central to our Force Plan set by Chief Constable 

Harrington.   

•  Essex Police must adhere to the Victims Code, and the force has established 

extensive governance, data audit, performance compliance, and development of best 

practise to achieve this, which has enhanced victim communication since 2022.  This 

includes Chief Officer oversight, led by Assistant Chief Constable 

 who chairs a 

force Victims Board, during which compliance of each Essex Police command is 

inspected.  The Force has a Victims Manager whose role includes the development 

of best practise to improve victim communication, including the introduction since 

2022 of innovative practises such as the Victim Engagement Portal, which improves 

our communication with victims.  We have also launched a victim survey, capturing 

the victims voice and their experience of our service.  This data will be incorporated 

into a data dashboard, allowing us to review what victims are saying and improve our 

service. 

•  Essex Police has updated policy and procedure to direct action to be taken to 

investigate crime, support victims, and share information.  Of key importance is 

procedure B0602 Investigation of Crime, updated in September 2025 which states at 

3.7:  

“Essex Police is committed to the protection of vulnerable adults and children. Although 

every situation is different it is recognised that abuse can take many forms. Abuse might 

consist of a single act or repeated acts of abuse. Safeguarding considerations should be 

constantly re-assessed throughout the life of the investigation as enquiries progress.” 

 
 
 “Prior to filing any Athena record, the officer owning this record is responsible for completing 

the referral to the appropriate department or agency. Failure to do this must be justified on 

the Athena record. 

Copies of all referral documents and e-mails must be uploaded to the Athena investigation. 

An outcome for all referrals must be obtained and documented on Athena detailing what 

action has been taken to advance the welfare or protection of victims and where appropriate 

witnesses. Athena investigations should not be closed without such an outcome.”  

•  As discussed during the inquest hearing, the Officer in the Case for Ms Coulibaly`s 

crime on 13th March 2022, did not update the Athena log with relevant contact and 

updates nor inform EPUT.  This has been addressed with them and their supervisor 

by reflective practise and learning which has been completed.    

•  Following this inquest, a working group of senior leaders and operational experts has 

been formed to ensure our victim update and crime closure procedures are clear and 

achievable for officers and staff as to what contact to and from victims must be 

recorded and where on Athena.  This work will be completed by the end of February 

2026.  

•  For repeat medium or high-risk victims of Hate Crime, such as Ms Coulibaly, Essex 

Police provide tailored support through dedicated Hate Crime Officers.  Victims are 

offered clear reporting routes, safeguarding advice, and signposting to partner 

agencies such as Victim Support and community-based organisations.  Where 

appropriate, referrals are made to statutory partners such as Social Services and 

Fire, for emotional and practical assistance.  We signpost victims to other appropriate 

services such as Tell Mama, CST, Hate Incident Report Centres and Essex 

Restorative and Mediation Services. Our approach prioritises empathy, 

confidentiality, and building trust, ensuring victims receive comprehensive care 

throughout the criminal justice process.  This victim support is documented in forces 

HC2 support booklet which is provided to victims of Hate Crime.  There is a data 

performance process established through our Victim Engagement Portal to check the 

HC2 support booklet is provided. 

2.  Contact Management Command Recording and Escalation 

Our Contact Management Command (CMC) deals with all emergency and non-emergency 

contact from the public and partner agencies.  This is a complex, high volume and high-risk 

area of policing, through which we fulfil our initial assessment and response and provide the 

 
 
 
 best service possible.  Our Quality of Service team which was referred to during the inquest 

hearing due to the contact they had with Ms Coulibaly, was disbanded as part of efficiency 

savings several years ago, and all public contact is now led within the CMC.   This command 

has considered the risk identified by HM Coroner and have completed the following since 

2022 to address this:  

•  The Concern for Welfare policy which was detailed during the inquest hearing and 

sets out the police response to such calls has been superseded by the Right Care, 

Right Person (RCRP) policy D 0800 and procedures D 0801 to 803.  These came 

into effect in early 2024 and follows national guidance which was developed with 

partner agencies including the NHS.  These procedures establish that the right 

agency deals at first point of contact, and then throughout an incident.  This provides 

clarity to Essex Police officers and staff to make operational decisions when 

responding to call for service involving medical support, physical, and mental health, 

from members of the public or partner agencies. 

•  Procedure - D 0801 RCRP – Concern for Welfare, provides clarity to the police and 

partners on when a concern for welfare request will, and will not, become a police 

responsibility to respond. This sets out that police may owe a duty of care, and 

therefore may have a duty to respond where:  

1.  There is a real and immediate risk or threat of harm to life or property: 

2.  The vulnerable person or child is suffering or are at risk of suffering 

immediate and serious significant harm as set out in Section 47 of the 

Children’s Act 1989 and further described in the SET Safeguarding and Child 

Protection Procedure 2022. 

3.  It is reasonably believed that a crime has been committed or is about to be 

committed. 

4.  Attendance of a police officer is necessary to prevent a Breach of the Peace.  

•  Within the CMC, this change in policy has been supported by the introduction of new 

incident headers on our Command and Control system (STORM) aligned to these 

changes, with a clear call script for Contact Handlers to utilise when dealing with 

such calls for service, whether by the public or partner agencies, which guides them 

to a proposed decision and outcome.  

•  This procedure makes clear that the National Decision Making model (NDM) 

underpinned by the THRIVE risk assessment tool will be used by staff to assess risk.  

 
 
 
 The document describes the elements of the THRIVE risk assessment, and 

specifically in relation to vulnerability, highlights:  

1.  Vulnerability is defined as: “a person is vulnerable if, as a result of their situation or 

circumstances, they are unable to take care or protect themselves, or others from 

harm or exploitation”; 

2.  A person may be vulnerable due to them being a Victim of crime, or due to their 

personal situation or may be vulnerable due to their current circumstances, at the 

time of the incident; 

3.  When assessing vulnerability, the following factors may indicate someone is 

vulnerable: 

1.  Family Circumstances;  

2.  Personal Circumstances; 

3.  Health & Disability;  

4.  Equality and Diversity;  

5.  Economic Circumstances;  

6.  Repeat Victimisation. 

The procedure highlights that any specific threat should be recorded verbatim and 

that where circumstances or information which is likely to alter the risk assessment 

changes, and the incident is not the primary responsibility of the police, it is 

incumbent on staff to ensure the changes in circumstances/risk assessment are 

passed to the relevant authority. 

•  This procedure also makes clear that any re-grading of the risk or response because 

of changes to circumstances or information must be recorded on the incident, with a 

re-THRIVE assessment, and any downgrade of response level must be ratified by a 

supervisor.  

To ensure these procedures are understood and consistently delivered by operational 

officers and staff in our Control Centre, the following has been implemented: 

•  CMC training programmes include the above policy and procedures as part of the 

new recruit programme for Contact Officers and staff.  

•  There is specific training in relation to incident recording and use of the NDM and 

THRIVE. 

•  Call scripts (as referenced above) have been introduced for RCRP incidents to guide 

Contact Handlers through incident handling to identify whether police should or 

 
 
 should adopt responsibility and attend. Ensuring only those incidents which are policy 

compliant and require an immediate response are adopted, or the caller/agency 

advised and directed to more appropriate agencies accordingly.  

• 

Introduction of Continual Professional Development (CPD) days for Contact staff 

have included refresher inputs on RCRP, THRIVE, and policy compliance, including 

re-thrive, incident response grade changes and escalation processes, and including 

supervisory oversight and responsibility.   

•  Strategic oversight is managed by the Assistant Chief Constable led RCRP & Mental 

Health Oversight Board.  This facilitates engagement with partner agencies from 

across the county. 

•  Call script compliance is included as part of Contact Management Quality and 

Compliance Checks (QCCs) reported on monthly to the Command Team.  

•  Numbers of RCRP incidents and dip checking of content/policy compliance are 

additionally reviewed as part of the Contact Management Daily Management Meeting 

performance metrics, by the Force Incident Manager Inspector, and the Command 

Duty Officer.    

Essex Police has an escalation process detailed in our Command and Control of Incidents 

procedure at 3.7.2, to ensure decisions made by a member of staff that Essex Police will not 

attend a call for service, or to change the attendance grading, are reviewed by a supervisor 

to ensure this is appropriate and complies with procedure.  The Command and Control of 

Incidents procedure states that if there is no agreement between the Essex Police 

supervisor and another agency requesting our attendance, this will be raised to the Force 

Incident Manager for review.  Failing resolution at that point, the matter will be referred to a 

higher rank for a final decision.  

3. Investigation Management Standards 

The investigation of crime is a core function of policing and one we continually aspire to 

improve.  In relation to the risks raised by HM Coroner, the following action has been taken 

since 2022.  

•  Essex Police has made notable progress in improving Case Action Plan (CAP) 

compliance through the work of the Investigations Improvement Board (IIB).  The 

board has driven initiatives such as the Volume Crime Investigation Improvement 

Plan and the deployment of investigation support interventions, which resulted in 

approximately a 20% increase in audit and inspection compliance.  The compliance 

 
 
 rate in October 2025 was 90.8%.  These improvements were supported by locally 

identified coaches and structured interventions for acting sergeants, ensuring 

consistency in investigative standards. Additionally, the board has focused on 

enhancing investigative workloads, screening strategies, and CAP adherence, 

aligning processes with national recommendations and performance benchmarks.  

•  Governance of compliance is underpinned by a robust framework managed through 

the IIB’s Terms of Reference which is overseen by ACC 

 who has responsibility 

for crime. The governance structure ensures accountability at multiple levels, with 

Superintendents tasked to implement local oversight and discharge 

recommendations from the Audit and Inspection team. The IIB agenda integrates 

reviews of bail, crime, and victim care obligations, shifting from a purely compliance 

tool to a quality assurance measure.  Regular audits, dip-sampling, and performance 

meetings feed into this governance model, supported by clear direction from senior 

leadership to maintain standards and embed continuous improvement across the 

force. 

•  Essex Police now has a Chief Superintendent who leads a Volume Crime 

Improvement Programme.  This has seen activity which has supported the 

improvement of investigation standards.  Examples of their completed work include 

the use of a team of two Detective Sergeants and four Constables who worked in 

each area of the force to raise knowledge and standards.  Training films have been 

produced to reinforce key skills, assist investigative standards, and workload 

management.  A central repository is being designed for all investigative best 

practice.  

•  Regarding the specific investigation of Hate Crimes, the force has a dedicated Chief 

Superintendent with strategic responsibility for our Hate Crime Policy & Procedure 

and liaison with other agencies and partners.  They are supported by dedicated Hate 

Crime Officers.  This Chief Superintendent chairs a Hate Crime Delivery Board in 

which they review performance and ensure operational compliance with our Hate 

Crime Procedure.    

•  Training inputs have been provided to Neighbourhood Policing Team Officers (who 

investigate medium and high-risk Hate Crime) to support their investigation standards 

and victim care.  These will take place again during 2026.  

•  The Force has specific Hate Crime Policy & Procedure, which is updated every year, 

last in December 2025.  The force completes monthly dip checks of all investigation 

types through Inspectors which will include Hate Crimes.  The results of these are 

 
 
 reviewed at the Force IIB.  In addition, additional Hate Crime audits commenced on 

5th January 2026 which are reported to the Hate Crime Delivery Board.  

4.  Safeguarding Pathways and Referrals 

Since 2022, Essex Police have established a Mental Health Triage team to improve 

safeguarding pathways and referrals.  They are a strategic department within our Strategic 

Vulnerability Centre (SVC) that works with partners to provide a holistic overview of mental 

health across Essex and exists to bridge the gap between the police and partner agencies.  

They work with partners regarding mental health policies and procedures to ensure they are 

collaborative and fit for purpose. This has been achieved by:  

• 

Identifying and supporting individuals of concern where mental health is a factor.  

The team develop multi-agency tactical plans, that aim to mitigate the risk of this 

individual, both to themselves and the wider public.  This is managed through a 

Mental Health Risk Management Board, which is the tactical forum to discuss 

individual cases.  

•  Assisting with training regarding mental health matters to ensure officers and staff 

are kept up to date with the latest updates in law, policy and notable news events 

that may highlight learning points for the force and ongoing development.  

•  Researching and identifying best practice from other Police Forces and NHS Trusts 

around the UK to learn, share and implement to continually enhance the service 

delivery.   

• 

Improving information sharing between agencies.  

•  The team work to understand the victim and perpetrator experience for those 

suffering mental ill health through the criminal justice system.  

•  When referrals are made to the team by an officer or staff, and the person is known 

by EPUT, the team will share information with them if there is a concern for the 

person. 

• 

If the person referred is not known or open to EPUT then the referrer will be updated 

that EPUT do not accept such referrals, but the team will identify other options for 

consideration.  If a person is not known to EPUT but there is a significant risk, officers 

will be instructed to override GDPR for safeguarding purposes and make a referral to 

the GP.  

 
 
 
 •  The Essex Police Mental Health Triage team have developed Mental Health Risk 

Management Briefings (MHRMB) which can be requested by police or partners.  The 

aim of this meeting is to bring all agencies involved with the subject together, or 

introduce agencies into the process, that need to have some involvement to manage 

the risk that the subject poses to themselves or the wider public.  

• 

If the MHRMT are requesting a risk management meeting, then the same process is 

followed other than the MHRMT will contact EPUT with our concerns and ask them to 

clarify who the interested parties are and call a board.  

These measures demonstrate Essex Police’s commitment to learn from the risks HM 

Coroner identified following this tragic death, and to prevent future deaths through a culture 

of continuous improvement. 

We welcome the opportunity to strengthen our service.  If further detail is required on any of 

the actions above, I will respond at your direction. 

Yours faithfully, 

Chief Superintendent 

Essex Police