Reports of domestic incident prior to child sustaining serious injuries - Greater Manchester Police, June 2020
On 12 June 2020, Greater Manchester Police (GMP) opened a domestic incident log at an address in Worsley, Greater Manchester. A neighbour had reported hearing a man and woman involved in an incident where he had locked her, and their child, out of their home. The man was reportedly heard threatening physical violence against the woman. The incident remained unallocated throughout the day. The neighbour contacted GMP the next morning to inform them that the man appeared to have locked the woman out and was shouting abuse. GMP officers attended and took the man to hospital at his request. The incident was closed as a domestic incident with a child present.
In the preceding weeks, neighbours' made numerous calls to GMP to report similar incidents.
On 9 August 2020, GMP were contacted by a hospital who informed them that the child registered at the address had non-accidental bruising to his face and chest and suffered a sudden deterioration in condition. Both the man and woman were subsequently arrested in connection with the child's injuries.
We obtained and examined documents that recorded the series of incidents between June and August 2020. We took statements from officers who attended the incidents and those involved with the criminal investigation into the child's injuries. We obtained supplementary statements from police officers working within in specialist teams and multi-agencies. We also reviewed radio transmissions and body-worn video footage. We compared all available evidence with relevant GMP policies and national guidance.
Our investigation concluded in July 2021.
We concluded there was no indication that a person serving with the police may have committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings. We did recommend some individual learning points for officers. We deemed it appropriate for this to be in the form of a structured conversation with line management.
We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system, and prevent a recurrence of similar incidents.
We identified several areas of organisational learning.
IOPC reference
Recommendations
The IOPC recommends that GMP reminds control room staff of the importance of accurately recording information provided during calls so that it can be communicated to attending officers and used to inform decision making and incident management.
A number of calls were made by a third party to the police concerning a man who was heard shouting abuse at his partner and their young baby. It was also alleged that the man had locked the woman and baby out of their flat. Not all relevant information was passed to the attending officers meaning that evidential opportunities were missed.
Recommendation accepted:
There are a number of systematic changes which the FCC have implemented, since the unfortunate incident highlighted by Op ITON.
GMP made the decision to move away from the previous Command & Control model. To this end the Incident Response Policy, which governs the way incidents are graded and then flow through the organisation was re-written and authorised for use by the Force Leadership Team (FLT) on the 18th January 2022. GMP has incorporated the Incident Escalation Policy and the Cross Border Policy into the Incident Response Policy there having a single policy which governs this area.
The New Incident Response Policy's main principle is that incidents grading and response will be guided by the risk contained within the incident rather than policy. This is aimed to ensure that the most best and most appropriate response is provided to the victim of each incident.
There are three steps to prioritising incidents;
1) THRIVE Risk Assessment
2) Grading by THRIVE Considerations
3) Prioritising Factors and Vulnerability Assessment Framework (VAF)
Step 1 - GMP use the THRIVE model, which is a nationally recognised risk assessment framework which stands for Threat, Harm, Risk, Investigation, Vulnerability, Engagement (THRIVE). A risk level of low, medium or high will be set to support the onward incident grade and trajectory.
Substantial investment has been made into the training and guidance given to the staff within; Call Handling, Radio Dispatch and Crime Recording and Resolution Unit, all of whom will play a vital role within the process of the new policy. This is supplemented by an increase governance around Dip Samples checking the quality of the THRIVE assessments.
Step 2 - In addition Further guidance surrounding the "Grading by THRIVE considerations"
Step 3 - The new policy highlights Basic and Additional Factors to consider within the THRIVE assessment and includes the Collage of Policing's, Vulnerability Assessment Framework (VAF).
This all provides a structure to identify and record information which benefits the decision making of the Call Handlers and Radio Operators.
There is new governance surrounding the THRIVE assessments at inception. Contact Management Supervisors and FCC Organisational Learning team, dip sample incidents in order to assessment the quality of this risk assessment. The aim is to complete 1000 dip samples per month to continue to monitor quality.
Following feedback from other DSIs and Organisational Learning, a review has identified 5 separate Touch Points which requires the completion of a THRIVE assessment. These include;
1) At Inception, (Already covered)
2) At Re-Grade
3) At Escalation
4) At Change of Circumstance,
5) At Closure of incidents (where officer's do not attend).
These THRIVE Touch Points mean that decisions made at critical junctures of the incident life cycle will have a structure which can be used to identify and record risk based decisions.
Training has been provided to all staff in relation to the change in policy and the THRIVE model.
Background checks
Dispatch officers will perform background checks on all graded incidents. The Force contact centre have introduced a minimum standards for back grounds checks to be completed at all stages of the process including Low risk assessed incidents.
Escalation plan
We have now implemented an escalation plan for both dispatch and division. Escalation for dispatch takes places by the 20 minute point and the action plan is invoked by the dispatcher. Once invoked, risk based touch points are required prior to being sent to a supervisor. An Area supervisor will escalate to district and once done, a flag is added to log. Escalation for district takes place by the 40 minute mark.
The IOPC recommends that officers are reminded of the importance of fully completing risk assessment forms and including their observations and additional context where appropriate.
On attending incidents at the property, officers completed a risk assessment with the victim. This recorded answers but lacked detail and the officer's observations about the situation.
Recommendation accepted:
In coming to this recommendation, the IOPC observed that the DASH documentation was completed by PC [redacted] at the scene with Female D. PC [redacted] recorded a number of ‘No’ answers to questions but the IOPC reviewed the BWV footage and noted that some slightly more expansive answers were provided in some areas. To the best of our knowledge, the IOPC has not identified what these were but the report states that Female D stated that neither she nor the baby had been abused by Male C.
The Public Protection Governance Unit (PPGU) has reviewed the IOPC report and in respect of this recommendation have assessed that this is individual learning, rather than organisational learning. This is based on the following assessment.
The IOPC have referenced the GMP Domestic Abuse Policy which outlines that the DASH should be conducted through a normal conversational mode, rather than a tick box exercise, that officers should apply professional judgement to make an assessment of risk and officers should include within the DASH any opinions on the demeanour of the victim if they refuse to answer a question, including their own observations. Additionally, all student officers have received domestic abuse training which is aligned with the College of Policing core objectives and includes the undertaking the DASH risk assessment during Phase 1-3 of the IPLPD and then again at Phase 4 of the training programme.
GMP feel that the policy is sufficient on this point and as such, individual learning should be taken with the individual officers to remind them of the importance of recording all information /observations
Additionally from June 2022, GMP is investing in DA Matters Training for the force. This is a College of Policing approved course delivered by Safe Lives. DA Matters will complement the training that has already taken place in GMP since this incident occurred, and has included two phases of training to all front line staff under the Think Victim heading which has focussed heavily on improving standards of responses to vulnerability incidents including Domestic Abuse.
The IOPC recommends that attending officers are reminded of the importance of obtaining independent evidence from the scene by speaking to witnesses.
A person called the police to report that a woman and her child were being verbally abused by the woman's partner. The person calling advised the call handler that this incident had been recorded on their mobile phone. This evidence was not obtained.
Recommendation accepted:
The IOPC report found that the officers were aware that this incident had been reported by a third party, but that they had not been made aware of the evidence that this third party had obtained. The officers did not speak to the third party who reported this incident.
The PPGU have reviewed this recommendation and assessed that individual learning should be undertaken with the officers involved. This is based on the following assessment;
Enquiries with witnesses are core functions in responding to incidents, and are reinforced in several force policies, including the Crime E Book, PIP1 Investigation Standards, and are re-iterated in accompanying policies such as the Domestic Abuse Policy.
The domestic abuse policy reminds officers that they should "Conduct primary investigative actions including the identification of the suspect, identification of witnesses, forensic opportunities, house to house enquiries and CCTV. Consider the recording of injuries (Photos, CSUI attendance), ensure the content of the 999 call has been reviewed and considered"
Furthermore, the PIP1 investigation standards also include reference to witnesses and state the following;
• Have details of all witnesses been obtained and added to the witness records on the crime?
• Have they provided statements or an account? Where are these recorded?
• Are any witnesses unwilling to assist? Why?
• Have any arrangements been made to speak to the witness at a later time/date? Provide the details.
• Are there any outstanding witnesses not yet spoken to?
Whilst it may not have been appropriate to attend at Female B's address at the time, there is nothing specific about this case that would have prevented the officers from making telephone contact with the witness
The attending officers have described how they were provided with some information prior to attending, however all officers have been provided with mobile devices which has functionality that enables them to review incident logs. Whilst it may not always be possible or practical to check these at the time of the incident, there is an expectation that officers should review incidents before they finalise the incident to comply with National Crime Recording Standards. Had the incident been reviewed, the information that Female B had recorded an incident would have been available to them.
The IOPC recommends that GMP should review how the Multi Agency Safeguarding Hub (MASH) records referrals and communication with partner agencies and satisfies itself that these processes are operating effectively and in particular, referrals are acknowledged.
The investigation found that a referral to partner agencies was recorded as having been made by the Multi Agency Safeguarding Hub (MASH). This referral was never sent. In addition, a safeguarding meeting requested by a partner agency did not take place but there was no follow up action or exploration of why this did not occur by the MASH.
Recommendation not accepted:
The PPGU had some concerns on the assessment from the IOPC in forming this recommendation as the IOPC report tended to indicate that no referrals were made in respect of this family, when this not the case. The PPGU conducted a review to establish what action was required to remedy the concerns highlighted in the IOPC report. DAB... was reviewed in conjunction with the IOPC report and liaison with DI [redacted] at Salford.
PC [redacted] created a DAB event following attendance at the incident on the 13th June 2020. PC [redacted]'s assessment was that the family needed support, and although [redacted] did not want details of this incident sharing with Social Services, she accepted that it could be. This was the first DAB recorded for the family. PC [redacted] from the MASH endorsed the log on the 14th June 2020 that they had made a CSD referral and also added the incident to the VA meeting which was due to be heard on the 16th June 2020. These were two separate meetings to achieve different objectives. The Children's Services referral was made, but an error lead to the referral into the Vulnerable Adults meeting being missed.
DAB/06FF/0002981/20 was re-opened on the 23rd June 2020 by PC [redacted] due to a strategy meeting request being made by Children's Services. This email did not contain a date/time for the meeting, but rather an indication that CSC wished to convene a meeting. The reason for the strategy meeting was based on the referral that GMP had made to Salford Children's Social Care about the incident on the 13th June 2020. The referral from CSC contained information from GMP, and additional information that may have been obtained from other partner agencies involved, such as the health visitor.
Point 186 on the IOPC report documents how Salford CSC were contacted by IOPC and confirmed that a strategy meeting was considered by them, but they decided that one was not required following a visit to the family home on the 17th June 2020. Salford CSC also stated that their records show no meeting request being made, however it is apparent from reading the DAB that this did occur and was made by Sophie Harwood.
DS [redacted] outlined in his statement to the IOPC the process for convening a strategy meeting.
The PPGU can attest that this was similar to how many MASH teams operated at that time. Due to Covid-19, many meetings were being arranged virtually, which meant that CSC would use an email calendar invite to diarise a meeting - that did not occur in this instance.
GMP recognises that best practice is to follow up on referrals made, however this is not always practical due to the volume of information being shared each day with partner agencies. Furthermore, "Working together to Safeguard Children" provides specific advice on referrals and includes that "Feedback should be given by local authority children’s social care to the referrer on the decisions taken. Where appropriate, this feedback should include the reasons why a case may not meet the statutory threshold and offer suggestions for other sources of more suitable support. Practitioners should always follow up their concerns if they are not satisfied with the local authority children’s social care response and should escalate their concerns if they remain dissatisfied"
In this instance, Children's Services did not provide feedback on the referral and the MASH team is unlikely to have followed this up as there appeared at that time, to be no specific child protection concerns and that this was a young family in need of extra support.
Furthermore in respect of the strategy meeting request, "Working Together to Safeguard Children" is also explicit that following acceptance of a referral by the local authority, a social worker should lead an assessment under Section 17 of the Children Act. If during that assessment information is gathered that results in the social worker suspecting that a child is suffering or likely to suffer significant harm, they should hold a strategy meeting. In this instance, we now know that CSC may have indicated that they may wish to hold a strategy meeting, but following their assessment under S17 of the Children's Act, they deemed it unnecessary.
It would be very difficult to set up a process to track and monitor all instances where a partner agency who stated an intention to hold a meeting, did not organise it.
The referral into the Vulnerable Adult meeting was missed and DS [redacted] has explained this oversight within his statement to the IOPC. GMP feel it is important to reflect that Male C was taken to hospital by officers voluntarily to assist with his mental health, and the referral was also completed to Children Social Care, which they received and acted upon by visiting the family, so support and intervention did occur.
The Multi Agency Safeguarding Hubs have undergone several changes since this incident occurred. The Investigation and Safeguarding Review Team led on this piece of work due to organisational changes, which included the re-introduction of Child Abuse Investigation Units. The staff working in these new teams underwent a 4 day course to refresh skills which included guidance on strategy meeting attendance and record keeping.
Additionally, the PPGU have undertaken several audits over the last 2 years on how processes operate within MASH teams, including the management of strategy meetings. This has led to guidance being circulated to all MASH teams in December 2020 about Strategy Meetings which included the purpose of strategy meetings, along with guidance on attendance and record keeping
We are satisfied having reviewed processes within MASH teams that no further changes are required at this time.
The IOPC recommends that GMP should reinforce with officers the importance of accurate recording of information entered on to Domestic Abuse Reports (DAB) so that related documents can be linked when incidents occur.
The investigation found that when completing the Domestic Abuse Report (DAB) that some information was completed inaccurately, including names being misspelt. This meant that some records were not linked and that other records were duplicated.
Recommendation not accepted:
GMP are concerned that the IOPC have not fully understood the functionality of ControlWorks and PoliceWorks in coming to this recommendation, therefore we seek to provide clarity and assurances on this recommendation.
When this incident occurred, GMP had within the last 12months moved from the previous record management system (OPUS) and the Command and Control system for incident handling (GMPICS) to iOPS.
The Force Contact Centre (Previously OCB) predominately uses ControlWorks to record incidents and deploy resources. PoliceWorks is the records management system.
Limited data sets are exported into ControlWorks from PoliceWorks to help inform ControlWorks operators of some key information, but not everything, therefore FCC staff are required to navigate into PoliceWorks for more information in certain instances. Additionally the functionality of being able to link people to incidents was new to ControlWorks and was not previously available in GMPICS. Whilst a person's name may have been manually entered in GMPICS, it could not be searched for.
The observation at Point 307 recorded that Male C's details were not added to the log (being Log 1383 3/8/20) until 4.25pm, which was two minutes after officers arrived at the scene, this was despite the log being updated at 1.05pm to say that the DASH from the 12 June was going to be checked to see if could be established who lived at the property.
It is best practice, that where possible, relevant people are linked to the incident log and FCC staff are reminded to do this. However, there are times when this may not always be possible due to a number of reasons, such as the urgency of the call being reported, information not available at the time of the call , demands placed upon the radio operator or as in this instance the caller not knowing who the occupants of the address were
From reviewing the incident log, Civ [redacted] records that they can see there is a domestic abuse event on the 12th June 2020. This information was available by viewing the history of events at the address. However, the full details of DAB would not be visible in ControlWorks and would require the operator to access PoliceWorks.
Whilst it cannot be assessed what other incidents Civ [redacted] was managing that day, it is reasonable to assess that they were managing multiple incidents and deployments, and this may have contributed to a delay in them retrieving this information before the officers were deployed.
Furthermore, the assessment at Point 313 is also inaccurate. "Having evidently struggled to find information from the 12 June log about the parties involved, the control room staff dealing with the incident on 3 August did not record the details of either Female D or Child X on that log, making any future searches relating to it equally problematic" There is no rationale from the IOPC that the radio operator evidently struggled to find the information, but we can assess there was a delay which occurred in accessing the information from PoliceWorks.
Additionally, it is important to emphasise the expectation of Force Contact Centre staff in linking people to incidents. This is due to the comment within Point 313 which states "control room staff dealing with the incident on 3 August did not record the details of either Female D or Child X on that log, making any future searches relating to it equally problematic"
It is not feasible for FCC staff to link everyone involved in an incident, and that is not the expectations of GMP. The incident is one element of recording information and where people can be linked they will, however, the primary place to record people is within the crime or other event that they are reporting, such as a Domestic Abuse Event, and this was completed correctly on DAB/06FF/*4040/20. Also the DAB was correctly linked to the incident to show the association between the two events. Additionally, as both Child X and Female D were created correctly, they are also linked the address which would show on a location search. See below extract from PoliceWorks
The second element of the recommendation originates from the misunderstanding on how events operate.
The investigation found that when completing the Domestic Abuse Report (DAB) that some information was completed inaccurately, including names being misspelt. This meant that some records were not linked and that other records were duplicated.
The PPGU have looked into this and believes this assessment stems from [redacted] being linked to the DAB twice.
PC [redacted] linked[redacted] at 20:05hrs, using the Person Reference (redacted). This Person Record appears to have been created on the 3rd August 2020 when PC [redacted] attended this incident. This record for [redacted] shows no alias names or any other information.
On the 6th August 2020, PCSO [redacted] locates another Person Record for [redacted]. This time, the reference is [redacted] and the name is recorded as [redacted]. Both records have the same name/DOB, but there is a minor variation in the spelling of [redacted]. The [redacted] record appears to have been created on the 13th June 2020 when PC [redacted] linked this record to DAB. There is no other information contained on [redacted] relevant to risk.
PCSO [redacted] has correctly identified that there is a duplicate person record and his action to rectify this was to link the 2nd Person Record to the event and the records were subsequently identified as potential duplicate records, which will result in both records being merged together once an assessment has been undertaken to ensure that this is accurate.
The observation from the IOPC at Point 320 states that " There appears to have been some duplication and confusion around the recording of the parties involved in the incident on the DAB documentation with differently spelt names showing twice before eventually being merged. Therefore, any information recorded against their names originally may not have been available to PC [redacted] when she created the August risk assessment.
GMP recognises that data quality is an area for improvement, and in this instance the decision by PC [redacted] to create a new Person Record was incorrect, as there was already one in existence. In creating a new Person Record it is unlikely that she was aware of the one previous incident between the couple (DAB/06FF/*2981)
To offer assurance to the IOPC since this incident occurred, there has been a number of changes to the way in which PoliceWorks searches are made which provides officers' with better search methods to identify duplicate records, especially when there may not be an alias recorded for that person, and a name could be misspelt.
The IOPC recommends that GMP reminds officer who attend incidents of domestic abuse that accounts taken at the scene should be compared prior to leaving the scene and any inconsistencies recorded and additional information gathered where appropriate.
When police attended an incident at the address, both parties were separated and each gave an account of what had happened. There were differences in the accounts provided but these were not probed by officers.
Recommendation accepted:
The IOPC investigation identified some minor discrepancies which occurred in one of the incidents. PC [redacted] BWV indicated that Female D agreed that her details could be passed to social service at the end of the DASH interview, and this was somewhat at odds with the entry on the DAB made by PC [redacted]. Furthermore, there was a slight variance in the account of Female D and Male C, in that Female D states that they had not been arguing and Male C had stated that they had argued over cigarettes.
From the incident on the 3rd August, PC [redacted] has recorded on the DAB
"The only concern for officers was [redacted] asked multiple times about social services being called now police had attended. She explained her case had just been closed and so she didn’t want the case reopening and stated that if they had an argument then her case would have been reopened. It's possible that [redacted] has denied an argument earlier in the day as she was worried police would get social service to reopen her case. It has been explained to [redacted] that Social services wouldn’t be taking her baby away unless there was serious risk of harm but she was scared this would happen.
On the DASH risk assessment PC [redacted] records that "referrals refused"
The BWV footage showed that when asked by PC [redacted] at the end of the DASH interview ‘would you like in regards to support with the baby, would you like a support or referrals anything like that?’ Female D initially stated ‘not really’ and that Social Services had already put something in place for them. When further asked ‘if they do want to speak to you or any team wants to get in touch are you happy for that, you happy with your information to be passed on just for them to give you a bell and just check everything’s ok?’ Female D nodded her consent.
It is recommended that individual learning is undertaken with PC [redacted] and PC [redacted] to address this recommendation. They have correctly separated the parties to obtain independent accounts however, it appears that Female D was reluctant to have the information shared with Social Services; however Female D did tell the officers that Social Care had already been involved and was worried that they would re-open the case. The officers themselves assessed that there was a limited support network in place for the family, as such the DAB should not have been considered to be Standard Risk and had PCSO [redacted] not identified the requirement for a referral, this would have been missed.