Police actions relating to a teenage boy’s arrest, welfare and disappearance prior to his death – British Transport Police and Metropolitan Police Service, September 2020
On 30 August 2020, a 17-year-old was arrested by British Transport Police (BTP) officers following an incident at East Croydon Railway Station and taken to a Metropolitan Police Service (MPS) custody facility at Croydon. He was released from custody the following day and returned to his home address.
On 1 September, the teenage boy was reported missing after he had left his home address and the MPS began a missing person investigation. He was graded as a medium risk missing person. The following day, he was hit by a train at South Croydon train station and died.
On 2 September, we began an independent investigation after we received mandatory referrals from the British Transport Police (BTP) and the Metropolitan Police Service (MPS), as both forces had been in contact with the teenage boy in the days before his death.
Our investigation examined the steps taken to safeguard the teenage boy during his time in police custody, the police response after he had been reported missing and whether any police action caused or contributed to his death. We compared the decisions and actions taken by the police against local and national policies, procedures and legislation.
During our investigation we reviewed MPS and BTP documents in relation to arrest, detention in custody and missing person reports. We also took statements from officers and staff members from both police forces.
Our investigation concluded in August 2021. We waited for all external proceedings to be finalised before publishing our findings.
Our investigation found that no officer committed a criminal offence or behaved in a manner that would justify disciplinary proceedings.
We identified individual learning for officers serving with MPS and BTP.
We advised the performance of two MPS inspectors should be addressed. This related to the missing person investigation and failure to share information and to review outstanding missing persons investigations.
We advised the MPS that it should also address the performance of three officers in custody, to remind them of the importance of adding accurate information to the custody log and of the appropriate level of detail to be included in risk assessments.
We advised BTP that it should address the performance of two officers involved in his arrest and subsequent criminal interview and remind them of their responsibility to complete safeguarding forms for vulnerable members of the public.
In March 2023, an inquest concluded that the teenage boy died by suicide.
The jury identified there were several factors that contributed to his death, which included a failure by social services to share information with the police regarding his vulnerabilities. Police forces also failed to adequately share risk information with each other and to complete a mental health assessment whilst he was in custody.
We carefully considered whether there were any organisational 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.
In this case, the investigation identified areas of organisational learning.
We recommended BTP ensure their staff are aware of the necessity of completing appropriate safeguarding and risk assessment forms for vulnerable persons, after we found no safeguarding forms were completed for the teenage boy, even though he was vulnerable as a youth.
We used a different legislative power to issue a recommendation to the MPS. This requires the police service to respond to our learning with their acceptance and proposed resolution, if applicable.
IOPC reference
Recommendations
The IOPC recommends that the Metropolitan Police Service (MPS) amend their custody policy to include a responsibility on MPS staff to ensure safeguarding forms are completed by them for vulnerable members of the public who they come into contact with following arrest by another police force.
This follows an IOPC investigation into police interaction with a vulnerable 17-year-old male in the days prior to his death. Two days before his death, the male had been arrested by British Transport Police officers. He was then transported to an MPS custody suite. Despite various indications that he was vulnerable, no Merlin Pre-Assessment Checklist or other safeguarding form were completed in relation to him, by MPS officers.
MPS custody policy states that arresting offers are responsible for completing any safeguarding forms. However, the IOPC were unable to find any reference within the policy on who has safeguarding responsibility when the arresting officers are not from the MPS. This indicates a gap in MPS custody policy in relation to who has safeguarding responsibility when the arresting officers are from another force and can lead to a situation where no safeguarding is put in place for a vulnerable member of the public. This is due to the fact the MPS custody staff have no way to check or review whether safeguarding forms and referrals have been completed by officers from another force area.
Yes
Accepted action:
The Metropolitan Police Service (“MPS”) has reviewed and accepts this recommendation by the IOPC. The Met Detention Command is in the process of reviewing the existing MPS Custody Policy to include a responsibility on MPS staff to ensure they complete safeguarding forms for vulnerable members of the public who they come into contact with following an arrest by another police force or where there is no ongoing active investigation.
They are considering the inclusion of the following paragraph in the policy: “Any incident or information provided within, and during, the custody period that suggests that a detainee is vulnerable, for example, a disclosure relating to Child Criminal Exploitation (CCE), Child Sexual Exploitation (CSE) or a self-harm attempt (this is not an exhaustive list) then the information must be shared with the Custody Officer, the officer in the case (OIC) and any relevant partner agencies’ partners for ongoing risk assessment and intervention. Where the arresting officer or OIC are still available then the custody officer will direct them to complete a Merlin report (database for recording a safeguarding concern for any individual, child or adult) with the details of the incident in order that this can be reviewed by the relevant Multi Agency Safeguarding Hubs (MASH) and information shared where applicable. If any detainee is as a result of an out of force arrest or there is no active investigation ongoing i.e. the detainee has been charged and detained or is not detained under PACE (warrant) and there is no OIC or arresting officer available then a member of Met Detention staff must complete a Merlin to ensure a record is made, in addition to a custody record entry, and the information shared with our key partners.
Furthermore, the policy sets out that, “concerns should be documented on the custody record and the custody officer must ensure suitable safeguarding measures are implemented, including ensuring the investigating officer completes a NRM*. (N.B. Belief is more than mere suspicion. Unlike suspicion, which is based primarily on inner personal conviction, belief is stronger and founded upon assurance gained by evidence). If the detainee is under 18 years old and it is believed they are at risk of exploitation then a non-crime exploitation report (588) must be created with the appropriate flags.”
It is anticipated that the Senior Leadership Team will approve this inclusion during a meeting scheduled for 18th October 2022 and that the policy will be amended accordingly. The change in policy will be communicated to all Met Detention staff via OCU newsletters, briefing updates and Professional Development Days. *National Referral Mechanism - identifies and supports victims of human trafficking and modern slavery. It provides potential victims with a number of support services, including accommodation, legal advice and counselling.