Handling of missing person inquiry - Metropolitan Police Service, March 2021
In March 2021, a mother reported her son as missing to the Metropolitan Police Service. She raised additional concerns around his medical condition.
Our investigation concluded in June 2022.
Our investigation found that officers provided an unacceptable level of service to the man's mother.
She was misinformed that her concerns were being passed on to the relevant team dealing with the missing person’s report and that police were looking into this case, when the report remained closed on the police system and her information was not being passed on.
We also found that officers who initially dealt with the missing person’s report had very little understanding of his medical condition and an officer failed to note on the file concerns raised by the man's GP about his welfare.
Other issues included a worrying level of miscommunication between the MPS call handlers and the team dealing with missing person's investigations. In this case, some call handlers were still misinformed – days into the investigation – about the overall status of the investigation.
Our investigation found that the performance of three police officers and three call handlers fell below the standards expected and the force agreed they would undergo reflective practice to address the concerns identified. It was our view that their actions did not meet the threshold for disciplinary action.
Our investigation also found no evidence that police may have contributed to or caused his death, as the evidence suggested that the man was already deceased in the lake prior to police being informed of his disappearance.
HM Coroner determined at the inquest into the man's death that he died sometime in the early hours of 23 March.
We identified several areas of organisational learning and issued recommendations to the Metropolitan Police Service.
IOPC reference
Recommendations
The IOPC recommends that the MPS takes steps to ensure that officers and police staff provide accurate information to callers, and clearly explain to callers their decision making and actions, and ensure those actions are carried out.
This follows an IOPC investigation which examined the MPS handling of a missing person report. During the investigation, it was noted that a caller made several follow up calls to police to obtain an update in relation to their missing person report. During these calls, the caller provided the police with new information and reiterated their concerns for the missing person.
Police call handlers misinformed the caller that their concerns were being passed to the relevant team dealing with missing person reports and that the police were looking into their case, when in fact the call report associated with their missing person report remained closed on the police’s system and details of their calls were not being passed onto the relevant team.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
MPS Control Room operators should already provide accurate information to callers, however, the difficulty arises when a wealth of information pertaining to one incident is collated on one Computer Aided Dispatch (CAD) record or multiple CADs. It can become time consuming for First Contact (FC) operators when receiving a high volume of calls, to read through the information and find the relevant information to provide updates to callers.
Processes are currently in place to ensure that all calls received into Met Command and Control (MetCC) are assessed for risk / vulnerability by using the THRIVE+1 assessment grading of high, medium and low. This was incorporated into the Call Handling System (CHS) on 19th April 2023 and now every call received by the Control Room requires such an assessment before the CHS permits the call to be closed. Any updated information received from the caller will also be assessed accordingly and as per the MetCC Missing Person Standard Operating Procedure (SOP), despatch will ensure the details are passed to the BCU 400. (Basic Command Unit Operations Room Manager more commonly known as BCU 400)
In addition to the THRIVE+ assessment, which will reduce some of the risk and vulnerabilities carried in this area, MetCC Training Academy will implement further guidance to MetCC staff when dealing with such updates within their Professional Development Days that start in November 2023.
The THRIVE+ risk assessment model is included in the FC initial course content and delivery, which includes ongoing updates to ensure currency – this has been the case since 2019.
FC Operator and Supervisor ongoing development days to capture existing staff have been in place since 2022. There is also an ongoing piece of work to ensure greater coverage by the Training Academy to ensure all staff are captured, together with interactive displays on all FC floors, and email updates from MetCC Operations Support around THRIVE+ changes.
Whilst there are various documents available to call handers which provide guidance on specific call types. The change of focus on the critical aspect of risk, vulnerability and repeat callers is being addressed in a new policy document which is currently in draft and once approved will be published in September 2023. This policy will focus on a process of risk/vulnerability and move away from depending on the call type and this will be introduced to new call handlers training by November 30th 2023 and briefing all existing staff by March 2024.
The over downgrading calls between FC, despatch and BCU 400s is being strengthened. Where opinions differ, the Duty Inspector within the Control Room will make the final decision. This provides an additional level of oversight to ensure decisions are more accountable and reliance on all updates becomes imperative.
The MetCC Quality Assurance Review Team (QART) will randomly dip sample calls of this nature to identify further learning opportunities which will be implemented locally via Senior Leadership Team agreement.
THRIVE+1 is a decision making framework which helps to record the National Decision Model and identify key issues in the incidents the MPS deal with and the crimes we investigate.
The IOPC recommends that the MPS takes steps to ensure that callers who are making a missing person report receive an open and sensitive policing response that leaves them feeling heard and understood. Any action should include ensuring an appreciation and understanding of any medical conditions that the missing person has, and the risks associated with them being missing.
This follows an IOPC investigation which examined the MPS handling of a missing person report. During the investigation, it was noted that officers who had initially dealt with the missing person report had very little, or no understanding of the missing person’s medical condition and the potential risks that were associated with them having this condition.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and partially accepts this recommendation by the IOPC.
This information should be recorded by the operator and any update regarding medication the missing person is taking or relies on, should be updated on the CAD.
The danger, as identified in our response to the previous recommendation, is that information could be lost when a large amount is received and isn’t readily apparent to the call handler. Too much reliance is placed on initial calls and each operator must assess independently using previous calls as a guide only.
The THRIVE+ assessment should reduce some of the risk when recording a high, medium or low assessment in relation to the medication and the necessity of it for the missing person.
Operators will be reminded that such information should be recorded as described by the caller. Without possessing the necessary medical qualifications operators will make judgements around risk based on the information as provided by the caller. It is likely there will be many occasions where the medication listed isn’t known to the operator making it even more imperative that reliance is placed upon the information provided. Identifying the exact nature and effect of medication upon the missing person should sit with the BCU Resource and Demand Team (RaDT) through their follow up contact as that will start to form part of the investigative strategy.
Operators must take down the information provided and not make their own assumptions on conditions. This places them in a role of assumed knowledge and we are not medical professionals. Operators must enter what is told, ideally verbatim to avoid confusion, misinterpretation and doubt. Furthermore we need to move away from scripted ‘type’ call processes which will now be assessed on the information itself as opposed to a set of questions utilising the risk / vulnerability approach.
A focus on such calls will be passed to the MetCC QART team to enable random dip sampling to identify further learning opportunities for MetCC or the wider MPS, this can be implemented locally by the SLT. In addition, staff will be reminded of this on dedicated PDD days to ensure compliance.
We will remind operators / despatchers via the MetCC Academy the importance of accurately recording medication information when obtained via the caller as it pertains to missing persons, to allow the risk assessment to be made with the correct information.
It is not possible in all instances for MetCC operators/ despatchers to fully understand the risk of every condition/medicine taken. We will therefore continue to rely on the medical profession to give advice in this area and recognise the boundaries in terms of medical knowledge.
Under the current ‘Resource and Demand Team’ (RaDT) process for the handling of missing incidents on each BCU, there is a far stronger emphasis on informant engagement and the expectation to sufficiently understand the risk and vulnerabilities faced by the missing individual.
The ‘Informant Engagement’ guidance was designed subsequently to this and a number of other cases where thematic similarities were identified within the MPS. Training has since taken place which is aimed at officers deployed to the RaDTs and both this training and guidance is permanently available to officers on the dedicated resources SharePoint page.
In addition to this, the ‘Grip and Progression’ guidance has become a trusted guide and includes THRIVE+ threaded throughout the areas of triage, risk assessment and case review for all relevant officers involved in a missing investigation. Actions should be risk‐led and informed by a clear understanding of any and all risks presenting in each case. Risk elements presenting commonly in missing incidents are listed, including medical conditions.
The forthcoming development into a trained and dedicated Centralised Vulnerability Hub will further strengthen the response to this recommendation by becoming a dedicated and trusted single point of triage and risk assessment for all missing person incidents; this will raise standards of decision‐making, confidence and consistency of response. The project to implement this is currently ongoing.
The IOPC recommends that the MPS takes steps to ensure that all officers and staff that are dealing with missing persons investigations record all relevant information and act upon it. This includes ensuring that relevant teams dealing with missing persons investigations are informed of follow up calls received from informants, and relevant information received from partners and professionals is fully considered.
This follows an IOPC investigation which examined the MPS handling of a missing person report. During this investigation, it was discovered that MPS control room supervisors had failed to pass on new and relevant information from an informant to the team responsible for risk assessing missing person reports.
It was also noted that an officer working within the team dealing with missing person investigations, had failed to note on the missing person’s file, concerns that had been raised by their GP (General Practitioner) regarding the subject’s welfare. This meant that officers responsible for conducting risk assessments regarding the subject’s disappearance, were not aware of this information.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
This information should be recorded by the operator and any update passed to the relevant MetCC despatch pod for the knowledge of local officers dealing. The difficulty in lengthy cases where a large amount of information is received is that it can be time consuming to go through a lot of remarks and therefore updates can be missed.
A new THRIVE+ assessment grading of high, medium and low was implemented on the CHS on Wednesday 19th April 2023. Therefore, every call into police will require such an assessment before the demand can be closed. This means updated information received during ongoing missing person reports for example, will be assessed accordingly. In essence any call into MetCC for a policing purpose will have a CHS demand created and therefore a THRIVE+ assessment will be required. Pertinent and relevant updates will be considered as a high grading within the THRIVE+ assessment enabling such updates to be highlighted more clearly to despatchers therefore reducing the opportunities for the information to be missed.
The current Standard Operating Procedure (SOP) states: “Pass the details of the CAD to the BCU 400 to make a decision on reporting. The CAD should only be passed back to FC if the SMF/MISRISK has not been completed”.
This SOP and supporting information is available on the “Misper Guidance” page which is available to all MetCC staff on the MPS Intranet InfoPortal Hub (internal website).
The new risk / vulnerability process will negate this aspect as no CHS can be closed without the THRIVE+ grading being attributed to it. The addition of the recently launched automated “Met Text” system is another safety net to enable callers to have access to information. Met Text is a facility where the FC Operator will send a text message to the caller’s mobile number which includes full details of the Police reference, crime number details which the caller can easily find and then quote in future contact with the MPS or other agencies.
The implementation of the THRIVE+ model, introduces a consistent risk assessment process for calls received, lessening the likelihood of information being overlooked by FC operators and opportunities being missed.
With the introduction of THRIVE+ high, medium or low grading an opportunity is now available to assess each new piece of information. There is no guarantee that callers will speak to the same operator so by grading each update against THRIVE+ the important and crucial updates being passed to BCU 400’s will be more identifiable with appropriate actions taken.
Currently, when some appeals are made for information we put on a CAD which just contains basic information. Consideration will be given in implementing this for missing persons e.g. Terry Jones of 123 Brixton Road, SW8 is reported missing, the OIC is PC Smith, any calls should be passed to AS Ops and emailed to AS Mailbox – Missing Persons Unit.
This wouldn’t require any technical changes and would be easier for FC Operators to read and follow the instructions, rather than reading many CADs and therefore minimising the risk of pertinent updates and information being lost. This will form part of the transformation project which is reviewing all current MetCC policies, Service Level Agreements and processes. It should be noted that this can only be implemented once the BCU 400 has made the decision to show the subject as a missing person.
A focus on such calls will be passed to the MetCC QART team to enable random dip sampling to identify further learning opportunities for MetCC or the wider MPS. In addition staff will be reminded of this on dedicated PDD days to ensure compliance.
The MPS will be taking the following action through either re‐training / refresher discussions, we will ensure despatch operators pass on information to local 400’s in a timely fashion enabling accurate and timely assessments to be conducted.
Alongside the risk and vulnerability assessment this process will be tighter to reduce opportunity for information being missed, especially so for information pertaining to risk or vulnerability.
Whilst the MPS can and will seek to improve standards of investigation across missing person incidents, we can never discount incidents of individual failure. What we have and will continue to improve are procedures of ownership and oversight to ensure investigations are progressing according an accurate appreciation of risk and concern.
The current handling procedures within the Resource and Demand Teams (RaDT) cover 24/7 and retain dedicated supervision.
The initial and ongoing procedures for review remain structured with enhanced guidance of how reviews should consider intelligence arising since the last review and how this can influence incident development. This is within the attached Grip and Progression document further developed since this incident.
As with the other recommendations arising, this recommendation is thematic around the overall level of oversight an investigation is subject to. The development of the Centralised Vulnerability Hub will further enhance dedicated ownership and structured, professional handovers to the relevant BCU Missing Person Unit.
The IOPC recommends that the Metropolitan Police Service (MPS) provide informants with direct contact details for the team assessing and/or dealing with their missing person report.
This follows an IOPC investigation which identified there to be a worrying level of miscommunication between the MPS control room and the team dealing with missing person investigations. It was especially concerning that days into the investigation, some MPS call handlers were still misinformed and/or mistaken in relation to very basic information, such as the overall status of the investigation.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
Since this incident occurred and utilising key third sector partners, the MPS has developed an e‐factsheet which is in use across London. The intention is to share the factsheet to with every informant once a missing person investigation is commenced.
As well as informing around the expected process in the Metropolitan Police and signposting to trusted agencies who can offer professional support, the factsheet contains contact details for each of the twelve BCU RaDTs or Missing Person Units.
Given the current level of activity and progressive development of the MPS Centralised Vulnerability Hub, the detail within the e‐factsheet is about to become out of date and will not reflect the intended procedural changes or accurate contact details. Therefore the current intention will be to re‐draft the e‐factsheet and launch it alongside the commencement of the Centralised Vulnerability Hub – the project to implement this is ongoing.
The IOPC recommends that the MPS conducts a dip sample review of missing person reports which have been classified as ‘not missing’ to check that they are being correctly assessed.
This follows an IOPC investigation which examined the MPS handling of a missing person report. It was noted that the police originally classified the missing person as ‘not missing’ and the IOPC investigation considered that the decisions to classify them as ‘missing’ would have been justified at an earlier stage.
The IOPC also conducted a comparator review exercise which reviewed other missing person reports that had been received by the MPS. During this exercise, the IOPC found there to be other instances of where missing people had been incorrectly assessed as being ‘not missing’.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
Over the last five years, the MPS has sought to significantly improve responses to missing incidents; one of a number of strategies exists to determine when a missing investigation is justified and when on occasion, incidents do not warrant police intervention.
The police role in missing is to respond to risk, concern and vulnerability and to do this we must have both a decision‐ making framework and a clear process in place to allow and prompt that decision‐making. By determining safely what we will respond to, we can improve our response to identified risk and prioritise our responses accurately.
Currently in development is the MPS Centralised Vulnerability Hub (CVH). The Hub will be a single site team of trained, dedicated officers taking early ownership of every incident raised to the MPS and which is progressed to a CAD. Research will be conducted and early contact with the informant to further develop risk‐based necessity will follow in each case. This will be a vast improvement to the current process where consistency of knowledge and decision‐making remains an identified issue.
It is accepted that as a result of this recommendation, incidents not progressed as missing investigations will be considered as part of a monthly data‐product which will be subsequently dip‐sampled to ensure decision‐making and rationale is sufficient and any learning, where identified, can be applied within the CVH.
The IOPC recommends that the Metropolitan Police Service (MPS) provide the informant with information in writing about the missing person investigation process.
This follows an IOPC investigation which examined the MPS handling of a missing person report. It was noted that during the police’s missing person investigation, the informant had been very upset and frustrated by the apparent lack of police action.
It is recommended that the MPS provide informants with information in writing about the missing person investigation process, as this may assist with managing the informant’s expectations, by explaining the framework in which the investigation teams operate within, and how the level of risk attributed to the missing person affects the level of police response.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
The MPS has developed a suite of officer guidance particular to specific elements of the missing person response. As a result of this particular case and another close to the material time, the MPS developed an e‐ factsheet designed specifically to inform those reporting missing person incidents of the likely process that would develop.
The factsheet extends to two pages and presents as a leaflet. The first page documents the current MPS process for missing person investigation and highlights the risk assessment options and which part of the organisation will be responsible for case progression. The factsheet also signposts key third‐party support from trusted organisations including the ‘Missing People’ charity who can offer professional support to families and loved ones. The second page details contact options for relevant units across all 12 of the MPS BCUs. This is in use across London now.
Given the current level of activity and progressive development of the MPS Centralised Vulnerability Hub, the detail within the e‐factsheet is about to become out of date and will not reflect the intended procedural changes. Therefore the current intention will be to re‐draft the e‐ factsheet and launch it alongside the commencement of the Centralised Vulnerability Hub – The project to implement this is ongoing.
The guidance and expectation outlined in the resource ‘Informant Engagement’ includes the efforts officers should make to ensure the informant is regularly updated and their expectations managed.
The IOPC recommends that the MPS takes steps to ensure that processes and guidance are streamlined so that officers working on Missing Person Investigations do not use multiple documents and systems for the same purpose.
This follows an IOPC investigation which examined the MPS handling of a missing person report. It was noted that once the investigation had been declared 'high risk’, the investigation was run from CRIS (having previously been run on Merlin).
However, some officers continued to update the Merlin file after this point. It was considered that using two systems for the same purpose presented a level of risk in relation to the way in which information was shared and processed during the investigation.
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC.
Both currently and historically, expectation of MPS officers is to record all missing person investigations to Merlin – this platform is the dedicated system for the recording and logging of developing investigations.
It is both advised and within procedural flexibility that where an investigation becomes particularly complex or protracted, the CRiS system (Crime Report Information System) lends itself to easier and more structured investigative management. Therefore, in limited cases, the recording mechanism will shift from Merlin to CRiS. Where this occurs, officers are expected to make it clear on the Merlin report that updates have shifted to CRiS and to record the appropriate CRiS reference number.
However, we have recognised that in places, officers needlessly default to CRiS in all high risk cases. This is neither necessary nor conducive to assured, informed investigation.
Recently, via the bi‐monthly meeting held specifically for Missing Person Unit Detective Inspectors, the lead responsible officer for missing investigation has directed that this practice stops and that CRiS is only used tactically in the most appropriate cases; never by default. This message is clear within the delivery of the Detective Inspector Investigation Course (missing person input).
We do not see widespread use of other platforms or programmes which may restrict or conflict the detail on the Merlin investigation.
In 2024, the MPS will launch a new platform for the recording of all incidents. (CONNECT – A single platform).
Both Merlin and CRiS will be shut down in favour of this single, POLE‐based platform. This will minimise any opportunity for cross‐system use to virtually nil.