Investigation into police contact before a death - Northumbria Police, January 2022
On 3 December 2021, Northumbria Police recorded a domestic violence (DV) crime of common assault, after a victim alleged her partner had hit her head against a car. The victim did not provide a written statement to Northumbria Police and the crime was closed without Northumbria Police speaking to her partner, the alleged perpetrator.
On 9 December 2021, Northumbria Police recorded a DV crime of stalking/harassment as a result of the victim's partner attending her home address and removing personal belongings, including a mobile phone. He then posted messages on the victim's social media profile and sent messages from her personal accounts to others. The victim then disclosed historic assaults which had not previously been reported to Northumbria Police. However, at the time she did not provide further information about the historic assaults and so the crime was closed.
On 15 December 2021, Northumbria Police recorded a DV crime of assault occasioning actual bodily harm after the partner allegedly punched the victim whilst in a car. As a result, she sustained bruising all over her body. She provided a statement but did not give her support for her partner to be prosecuted. Northumbria Police did not speak to the victim's partner and the crime was closed.
On 21 December 2021, Northumbria Police recorded a DV crime of assault occasioning actual bodily harm as a result of a third-party Multi-Agency Risk Assessment Conference (MARAC) referral. The victim reported that her partner collected her in his car and punched her in the face causing a black eye. At the time of the referral to the IOPC, the crime remained open with Northumbria Police and unallocated to an officer.
At 1.16pm on 20 January 2022, the victim's mother contacted Northumbria Police reporting she found her daughter dead. She reported it appeared her daughter had been beaten up. Officers attended the address and the victim's parents reported that, at 11pm the previous night, their daughter had experienced a DV incident at the hands of her partner.
A post-mortem examination revealed ‘no pathological evidence of third party involvement’ in the victim's death.
On 25 January 2022, Northumbria Police made a mandatory death or serious injury (DSI) referral to the IOPC.
We did not investigate the circumstances of the victim's death as that is a matter for Northumbria Police and HM Coroner.
We are awaiting the inquest to conclude before publishing our findings.
We identified several areas of organisational learning for Northumbria Police.
IOPC reference
Recommendations
The IOPC recommend that Northumbria Police review training for Call Centre staff with regard to risk grading and that domestic violence incidents graded 1 or 2 receive a prompt response. This should be done by continuous dip sampling to check adherence to Call Centre procedures and that Northumbria Police should focus on the THRIVE model and the broader thinking around investigation of Domestic Abuse when delivering the forthcoming internal media strategy.
This follows an IOPC investigation whereby call centre staff were not aware of their responsibilities regarding reviewing risk when new information came to light or during incident reviews.
Recommendation accepted:
In June 2021, a new ICT system Smart STORM was implemented which is the new incident and resource deployment model used by communications operatives to create, allocate and manage incidents. This information helps inform deployment decisions. To further assist in managing the risk and demand, the THRIVE model is built into call scripts applied during the creation of the STORM incident. This is used for initial calls and to aid the management of the incident.
THRIVE call scripts are now utilised by all staff, except for Grade 1 incidents and where initial grading stands. This helps to ensure that risk is appropriately identified and graded to receive a prompt response.
Since 2017 all staff including Contact Handlers received training on the THRIVE risk model. The training focuses on the importance of THRIVE and RARA risk assessment models used as part of safety planning for domestic abuse victims. Consideration for the need to re-THRIVE and vulnerability matters, including situational factors are included within this training.
The training continues to be provided and is delivered during the initial training courses of new student intakes. An NCALT package covering Stalking and Harassment was delivered to officers Force wide in 2018 with a revised NCALT package delivered during protected learning days in 2023. A mandatory NCALT package encompassing Vulnerability Matters was delivered to all front-line staff in 2022. THRIVE inputs were held in 2022 for staff during their allocated protected learning days also.
Regular guidance is provided to and made available to staff by way of aide memoires on THRIVE and incident handling; this includes domestic abuse and stalking and harassment. This guidance is subject to review and kept up to date. There is now a direction that all staff have this document available and open for reference.
As part of the performance management framework (pmf), dip sampling is undertaken in 8 weekly cycles. Team Leaders within the Communications Department are responsible for and conduct the dip sampling of calls handled and incident management. This includes ensuring that the risk is managed appropriately and has been appropriately graded. Team Leaders are responsible for identifying any performance matters including around the use of the THRIVE model and the quality of the THRIVE. They look to address any areas of performance that are identified with a member of staff and work with Senior management around any remedial action required.
A ‘dip error’ queue within the ICT smart contact system has been introduced to allow any areas of concern to be highlighted to staff supervision and senior management. Issues identified are discussed with Contact Handler’s to ensure learning. Additionally, Team Leaders will review live time incidents and provide immediate feedback to staff and progress any remedial action where required.
Further focus on THRIVE quality occurs during the Communications Quality Assessment Group this includes domestic abuse. Any learning is addressed immediately with further learning cascaded to staff. Further THRIVE training is scheduled to be delivered throughout 2023.
Weekly meetings are chaired by Communications Management with a previous focus on domestic abuse. The Communications Management Team aim to conduct and audit focusing on domestic abuse during October 2023.
DA Matters training has been commissioned to be rolled out to initial response officers from the end of 2023 and the plan will be to build a training provision for Communications staff in 2024. The aim of this training is to support that broader thinking around domestic abuse.
THRIVE and broader thinking around investigation of domestic abuse features as part of our internal media strategy. Themes focused upon broader thinking and investigative mindset regarding domestic abuse were delivered during Spring/Summer of 2023. We continue to develop further internal media work focussed on domestic abuse which is planned to be disseminated Autumn/Winter 2023.
In August 2023, the Force policy regarding THRIVE and Re-THRIVE was updated.
The IOPC recommend that Northumbria Police should remind all investigative staff to pursue all lines of enquiry and that officers attending incidents document all intelligence received and upload it to policing intelligence systems. And that they are fully aware of the need to gather and record all evidence including CCTV, forensic and witness statements, which should be actively progressed at the earliest opportunity.
This follows an IOPC investigation whereby all lines of enquiry were not effectively followed and information that would have helped form present and future decision making was not adequately recorded on the correct policing systems. This also led to a failure to effectively follow up investigative opportunities to identify and gather more evidence of a domestic violence related incident as per the NDM.
Recommendation accepted:
Inputs on initial investigative response with a focus on the rationale for and necessity to gather and record all evidence including CCTV, witness assessment and evidence capture and maximising forensic opportunities, have been delivered to the ‘New to rank’ Sergeants and Inspectors courses held within the last 12-15 months. The overall aims and objectives of this course have been revised and a recommendation has been made via Force Governance Boards to continue provision of the Investigative Standards input to those officers on the promotion pathway as a mandatory pre-requirement to support for promotion.
Investigative assessments are documented on the crime record throughout the course of the investigation. Previously, force policy was amended to direct that domestic abuse crimes required an Inspector to finalise the crime where no action was to be taken when a suspect was named. In July 2023, we implemented the HMIC recommendation which is to ensure Inspectors conduct a ‘robust and auditable’ review when considering the finalisation of crime investigations with outcome 15 and 16. This recommendation was instructed and disseminated to Senior Management Teams Force wide. In addition, an ‘instruction aide’ was developed to guide Inspectors around the review considerations and the responsibilities upon them to do so. This aide along with FAQs was made available on the internal Force intranet as an instruction and further appended to the Safeguarding guidance hub contained within the internet for access to the guidance to support them in doing so.
In August 2023, the Crime Allocation and Screening Quality Team (CASQT) commenced the review of the Investigative Assessment Framework (IAF). Key messages are being prepared to formulate an internal circular for to remind officers and supervisors of the expectations.
Messaging around the need for officers attending incidents to document all intelligence received and upload this to intelligence systems is to be built into the overarching internal communications strategy.
Additionally, the above processes and pieces of work will feature as part of the overarching Internal Communications strategy focused on improving our response to domestic abuse which is ongoing and will continue throughout Autumn/Winter 2023.
It is our intention to reach officers using the Internal intranet platform. This will be used to communicate the instruction and messaging but will be appended to the safeguarding hub on the intranet as a point of reference to guide and support officers and staff.
Training circulars relating to domestic abuse and investigation have been circulated in 2023 however DA Matters training has been commissioned for to be rolled out to initial response officers from the end of 2023 and the plan will be to build a training provision for Communications staff in 2024. The aim of this training is to support that broader thinking around Domestic Abuse.
The IOPC recommend that Northumbria Police should remind staff of their responsibility to identify and respond appropriately to vulnerable victims and that supervision of incidents concerning vulnerable victims is robust and effective and that all available evidence/intelligence is imputed onto the policing systems, as per the force incident grading and deployment criteria.
This follows an IOPC investigation whereby information was either received or not recorded correctly and no escalation of the incident was made or no action had been taken to safeguard a vulnerable female victim of domestic violence. This should have led to a re-assessment of the response to the incident due to the inaction of Northumbria Police to arrest the perpetrator in order to safeguard the victim.
Recommendation accepted:
In addition to recommendation 1 above, there is an additional provision in the form of a Risk Management Desk (RMD) which is situated within the Communications Department. The RMD consists of a team of police officers supervised by a Sergeant who have the responsibility of overseeing and supporting the management of interim risk. This includes reviewing any incidents marked as vulnerable, with a particular focus on the Grade 2 vulnerable incidents which can include domestic related incidents. If the Contact handlers have deemed the incident to meet Grade 1 or 2 deployment criteria, the incident is sent to Resource Controllers to deploy in accordance with the grading and deployment policy. If the victim is deemed vulnerable, then the escalation process is adhered to if deployment criteria cannot be met.
In 2023 a direction was issued to Area Commands with an expectation that Response Supervision too manage vulnerability. This has been directed by Communications Department to Area Commands through recent updates.
Messaging around the need for officers attending incidents to document all intelligence received and upload this to intelligence systems is to be built into the overarching internal communications strategy.
Additionally, the above processes and pieces of work will feature as part of the overarching Internal Communications strategy focused on improving our response to domestic abuse which is ongoing and will continue throughout Autumn/Winter 2023.
The IOPC recommend that when investigating domestic violence Northumbria Police should use the investigative allocation framework (IAF) using the four point assessment on severity, complexity, solvability and vulnerability and that all decision rationale is clearly documented.
This follows an IOPC investigation whereby the investigative allocation framework was not adhered to and that there was no clear, detailed rationale documented for the decisions not to pursue a suspect led investigation or why this case should be closed.
Recommendation accepted:
Inputs on initial investigative response with a focus on the rationale for and necessity to gather and record all evidence including CCTV, witness assessment and evidence capture and maximising forensic opportunities, have been delivered to the ‘New to rank’ Sergeants and Inspector courses held within the last 12-15 months. The overall aims and objectives of this course have been revised and a recommendation has been made via Force Governance Boards to continue provision of the Investigative Standards input to those officers on the promotion pathway as a mandatory pre-requirement to support for promotion.
Investigative assessments are documented on the crime record throughout the course of the investigation. Previously, force policy was amended to direct that domestic abuse crimes required an Inspector to finalise the crime where no action was to be taken when a suspect was named. In July 2023, we implemented the HMIC recommendation which is to ensure Inspectors conduct a ‘robust and auditable’ review when considering the finalisation of crime investigations with outcome 15 and 16. This recommendation was instructed and disseminated to Senior Management Teams Force wide. In addition, an ‘instruction aide’ was developed to guide Inspectors around the review considerations and the responsibilities upon them to do so. This aide along with FAQs was made available on the internal Force intranet as an instruction and further appended to the Safeguarding guidance hub contained within the internet for access to the guidance to support them in doing so.
In August 2023, the Crime Allocation and Screening Quality Team (CASQT) commenced the review of the Investigative Assessment Framework (IAF). Key messages are being prepared to formulate an internal circular for to remind officers and supervisors of the expectations. This will feature as part of the overarching internal communications strategy focused on improving our response to domestic abuse which is ongoing and will continue throughout Autumn/Winter 2023.
It is our intention to reach officers using the Internal intranet platform. This will be used to communicate the instruction and messaging but will be appended to the safeguarding hub on the intranet as a point of reference to guide and support officers and staff.
DIP sampling together with an audit is to be undertaken during Autumn/Winter 2023 and a further review to follow in 2024 which will include the use of the IAF framework.
The IOPC recommend that that when closing domestic violence cases Northumbria Police should put in place a system of supervisory oversight in line with the HMICFRS VAWG Report Recommendation update dated 13 June 2023. This will allow supervisory oversight and that any closure of such cases is documented with clear rationale. A supervisor plan should also be put in place to effectively manage the incident and its closure. This should include a clear explanation detailing whether or not the suspect is to be arrested and should include historical and up to date intelligence to support the rationale for the closure decision.
This follows an IOPC investigation whereby a domestic violence investigation of a vulnerable female was closed without supervisory oversight of the whole circumstances of the investigation and the historical intelligence, or any detailed arrest/non-arrest rationale.
Recommendation accepted:
In July 2023, Northumbria Police implemented the HMIC recommendation which is to ensure Inspectors conduct a ‘robust and auditable’ review when considering the finalisation of crime investigations with outcome 15 and 16, those where there are evidential difficulties, or the victim does not wish to prosecute. This recommendation was instructed and disseminated to Senior Management Teams Force wide. In addition, an ‘instruction aide’ was developed to guide Inspectors around the review considerations and the responsibilities upon them to do so. This instruction aide along with FAQs was made available on the internal Force intranet (NIK) both as an instruction and further appended to the Safeguarding guidance hub contained within the NIK for access to the guidance to support them with those reviews relating to any such closures.
In addition, the existing crime investigation screens have been revised and amended to support Inspectors when completing such reviews. This template includes the rationale as to why a suspect was not arrested, and a requirement to consider the intelligence of both suspect and victim (historic and recent).
The procedure has also been updated with the Crime Allocation, Screening and Quality Team (CASQT) who are currently refreshing their policy. This assists with the quality assurance of the procedure. Crimes will be returned by CASQT to the relevant Inspector if not completed correctly.
In September 2023, dip sampling commenced around the adherence of the crime review procedure. A further audit is to be undertaken during Autumn/Winter 2023 and a further review to follow in 2024 to ensure compliance.
The above processes and pieces of work will feature as part of the overarching Internal Communications strategy focused on improving our response to domestic abuse which is ongoing and will continue throughout Autumn/Winter 2023.
The crime review procedure has already been built into the Performance Management Framework Whereby Senior Management are to conduct dip sampling of Inspector reviews relating to domestic abuse crimes to ensure compliance. This will continue to feature as part of those regular performance reviews.
The IOPC recommend that Northumbria Police should take positive steps to change the culture of closing cases without victim support, which seems to be a cultural and widespread issue around closing cases without victim support or a victim statement.
This follows an IOPC investigation whereby it was identified that there was a culture within Northumbria Police of failing to fully investigate all potential lines of enquiry, including consideration of suspect led investigations before closing cases of domestic related violence against vulnerable females, should those victims not wish to co-operate with the police investigation.
This would allow Northumbria Police to move to a more progressive and proactive culture with suspect focused actions, which should seek to take positive action regardless of whether a complaint has been received or not or if no victim statement has been made.
Recommendation accepted:
Northumbria Police have addressed this recommendation as outlined in response to Recommendation 6.
In addition to the points made within the response to Recommendation 6, Northumbria Police had previously devised a standards and expectations presentation to improve our approach to Domestic Abuse. Training was previously delivered to Inspectors and Sergeants.
To ensure this recommendation is further embedded, Northumbria Police have recently commissioned future training focussed on domestic abuse.
Domestic abuse training has been commissioned through the use of an accredited training provider ‘Safelives’ , who are to deliver the national ‘DA Matters’ training package. This is to be rolled out to initial responders from the end of 2023 and the plan is to build a sustainable training provision which aims to include the future training of our student officers. The aim of this training is to provide a holistic approach when investigating domestic abuse incidents and to support that broader thinking and the building of a wider investigative mindset.
Governance within the newly created Domestic Abuse Improvement Board will provide additional scrutiny to drive this improvement.
The IOPC recommend that Northumbria Police should ensure that when investigating domestic violence incident they undertake a holistic approach rather than dealing with incidents in isolation, in order to proactively identify any previous intelligence, domestic violence history, bail conditions for similar offences etc. when identifying risk and grading of incidents as well as decision making rationale for progression of the investigation.
This follows an IOPC investigation whereby decisions were made with regard to a domestic violence investigation in isolation and not adequately recorded with clear evidence led decision making rationale without using historical information to identify a holistic picture of the potential risks to the victim.
Recommendation accepted:
The points outlined in the above responses to recommendations, including recommendations 2, 6 and 7 indicate Northumbria Police’s efforts to set remedial action and the further plans to embed a holistic approach when responding to and dealing with domestic abuse incidents.
Those measures also seek to address improvements in adopting a proactive approach, to include identification and use of previous intelligence and subject history to support the appropriate grading and management of risk together with improving the decision making and rationale when dealing with such investigations.
In addition to previously mentioned scrutiny, further scrutiny of open cases takes place during daily management meetings which are chaired by Senior Leaders. This helps to drive those investigations and consider the risk to victims; and to ensure that the appropriate measures have been taken into consideration.
In 2023 the Crown Prosecution Service delivered training to officers across the Force to improve consideration and focus on evidence led prosecutions.
The previously mentioned commissioning of ‘DA Matters’ training seeks to educate staff around that holistic approach in understanding risk. This will support Northumbria Police in enabling that cultural change.
The IOPC recommend that Northumbria Police should ensure that all domestic violence crimes are being investigated by suitably trained officers and at an area commend level and investigated by CID teams and using a combination of PIP 1 and PIP 2 trained officers.
This follows an IOPC investigation whereby a supervising officer although experienced in handling domestic related violence cases had not completed the necessary training for the role.
Recommendation accepted:
All officers allocated to investigate Domestic Abuse cases are suitably PIP trained officers. Investigations conducted within CID teams are conducted with a mix of PIP1 and PIP 2 trained officers.
In addition, those investigations that are progressed by Response Policing Teams are overseen by Sergeants and Inspectors. Those investigations progressed within CID are overseen by Detective Sergeants and Detective Inspectors.
In July 2023 supervisors were provided with instructions and guidance to support them with the investigative review and decision-making process, as outlined in previous responses to recommendations.
PPDA investigations are now transferred to Professional Standards Department who have received an uplift with PIP 1 and PIP 2 trained officers.
The IOPC recommend that Northumbria Police should continue to adhere to their dip sampling policy of domestic violence cases in order to identify any improvement opportunities and put in place a clear and robust and documented plan for remedial action should any failures in procedure or policy be identified.
This follows an IOPC investigation whereby there were significant identified failures to follow policy and procedures in relation to a domestic violence related investigation.
Recommendation accepted:
To support this recommendation, Northumbria Police have taken the following action:
Scrutiny of open cases takes place during Daily Management Meetings (DMM), which are chaired by senior leaders. This helps to drive those investigations and consider the risk to victims; and to ensure that the appropriate measures have been taken into consideration.
Domestic abuse investigations are included in the performance management meetings where Chief Inspectors ensure Inspecting ranks are intrusively dip sampling those investigation types during each performance cycle.
In September 2023, dip sampling commenced around the adherence of the crime review procedure. A further audit is to be undertaken during Autumn/Winter 2023 and a further review to follow in 2024 to ensure compliance.
Additional scrutiny is conducted with partners during the monthly Domestic Abuse Operational Meeting attended by Senior Management representatives from Police and Criminal Justice partners. The purpose being to examine a sample of investigations finalised as crime code outcome 115/116, where no further action has been taken. The circumstances, evidence gathered, and decision making is examined to determine whether it was closed appropriately. Any remedial action or learning identified is progressed via Senior Management and shared within the newly created Domestic Abuse Improvement Board.
Further scrutiny and governance is provided within the newly created Domestic Abuse Improvement Board. This is chaired at Executive level and attended by Senior management representatives. The aim is to drive improvement in performance and ensure learning is identified and appropriately shared to improve practices.
The IOPC recommend that Northumbria Police remind OIC’s of their responsibility to consider Clare’s Law when dealing with domestic violence cases at all stages and whenever a domestic violence case is reviewed in order to safeguard potential victims. They should also consider putting in place a system of effective communication between officers, teams and the OIC before a Clare’s Law disclosure is dismissed, with clear documented rationale with regards to the decision made and communications undertaken beforehand.
This follows an IOPC investigation whereby there did not appear to be any serious considerations of any ‘Clare’s Law’ disclosure or any detailed rationale for why it was appropriate or not appropriate to do so.
Recommendation accepted:
The Multi Agency Safeguarding Hubs (MASH) has responsibility for Domestic Violence Disclosure Scheme (DVDS) and receives and act upon all ‘Right to Know and Right to Ask’ DVDS applications also known as Clare’s Law. All applications result in contact with the applicant or person at risk (PAR) as soon as possible. After contact is made some applications are not eligible for the scheme with others progressing to a full disclosure. All rationale is documented within the force’s workflow ICT system so that each application can be audited. In 2022 a total of 1521 applications were made for RTA. When speaking to a person at risk, safety planning is discussed, and advice provided whilst ICT systems are interrogated on the subject. Out of the 1521, a total of 952 were eligible. From the 952 a total of 523 disclosures were made. For the remaining ones eligible but no disclosure made, this is because there was nothing to disclose, however all applicants or persons at risk are recontacted and advised of the outcome and again provided with Safety Planning advice.
The current practice has been reviewed and remains strong, having been reviewed against the new Home Office DVDS Guidance which was published in April 2023. Northumbria Police is reviewing the new guidance to consider the embedding of the process moving forward.
DVDS warning markers are also updated on NPICCS so that all officers and staff are aware of the DVDS application.
An Information and Instruction Policy is readily available and easily accessible on the force NIK website and although the policy is confirmed to be accurate, it is not detailed enough. Recommendations are being made with a view to making improvements to its content on review of the new issued guidance in April 2023.
The reminder of DVDS and the importance of a proactive approach to using Clare’s Law features as part of our current Communications strategy.
Refresher training will be factored in as part of the future training plan. A previous force broadcast was issued in 2018 with guidance on Clare’s law. This included the link to the DVDS Scheme and the requirement upon officers who must complete Right to Know when they identify risk. This is being refreshed as part of our 2023 Communications strategy.
The IOPC recommend that Northumbria Police should ensure that all staff involved in an investigation effectively document all policy decisions, investigative plans and lines of enquiry, ongoing progress, case reviews, and victim contact as part of the record of investigation.
This follows an IOPC led investigation whereby it was identified that there appeared to be insufficient detailing of policy decisions, investigative plans, investigative lines of enquiry, case reviews and victim contact throughout the reported incidents.
Recommendation accepted:
Northumbria Police have taken the action outlined in Recommendation 10 to ensure domestic abuse investigations are robustly scrutinised.
As previously outlined in some of the above recommendations, In July 2023, Northumbria Police implemented the HMIC recommendation which was to ensure Inspectors conduct a ‘robust and auditable’ review when considering the finalisation of crime investigations with outcome 15 and 16, those where there are evidential difficulties or the victim does not wish to prosecute. This recommendation was instructed and disseminated to Senior Management Teams Force wide. In addition, an ‘instruction aide’ was developed to guide Inspectors around the review considerations and the responsibilities upon them to do so. This instruction aide along with FAQs was made available on the internal Force intranet (NIK) both as an instruction and further appended to the Safeguarding guidance hub contained within the NIK for access to the guidance to support them with those reviews.
In addition, the existing crime investigation screens have been revised and amended to support Inspectors when completing such reviews. This template includes within the investigation strategy aspects such as suspect and victim management and the need to rationalise decision making. Amongst other requirements is the need for to consider the intelligence of both suspect and victim (historic and recent) and the requirement to document contact made with victims.
The procedure has also been updated with the Crime Allocation, Screening and Quality Team (CASQT) who are currently refreshing their policy. This assists with the quality assurance of the procedure. Crimes will be returned by CASQT to the relevant Inspector if not completed correctly.
In September 2023, dip sampling commenced around the adherence of the crime review procedure. A further audit is to be undertaken during Autumn/Winter 2023 and a further review to follow in 2024 to ensure compliance.
The above processes and pieces of work will feature as part of the overarching Internal Communications strategy focused on improving our response to domestic abuse which is ongoing and will continue throughout Autumn/Winter 2023.
The crime review procedure has already been built into the Performance Management Framework whereby Senior Management are to conduct dip sampling of Inspector reviews relating to domestic abuse crimes to ensure compliance. This will continue to feature as part of those regular performance reviews.