Hannah Warren

Coroner's concerns

AI summary

There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.

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(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling; (2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.

(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.

(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.

(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.

(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.

Responses

3 respondents

National Police Chiefs Council and College of Policing Police / Law Enforcement

5 Apr 2023 PDF

Noted

The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. (AI summary)

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Dear Mr Ramsay, This response is submitted on behalf of the College of Policing and National Police Chiefs’ Council. Thank you for your Regulation 28 – Preventing Future Deaths report relating to the death of Hannah Warren. The College of Policing and NPCC offer our condolences to Hannah’s family and friends. Hannah’s death happened in 2016. Since that time our instructions and guidance on managing missing persons enquiries and the use of PNC and ANPR have been reviewed and updated. Missing Persons Authorised Professional Practice (APP) sets out clear processes and procedures for investigating these cases including the risk assessment and risk management processes that should be followed. The Regulation 28 report does not contain a great deal of detail on the circumstances of Hannah going missing, but, on the information available, it seems reasonable for her to have been graded a medium risk missing person. There then seems to have been action taken to trace her, including the updating of PNC and creation of the ACT alert. The issue in this case arises because of the nature of the ACT (an abbreviation of ‘action report’) alert. Current College instruction on this system is clear- “An ACT report should be used where it is reasonable and proportionate for that vehicle to be subject of national circulation for the purpose of appropriate action being taken should the vehicle come to notice or when an ANPR intelligence marker normally circulated as an entry on a Vehicle of Interest (VOI) list contains warning signals which may compromise officer safety. There is an expectation when adding an ACT report that some form of action will be taken should the vehicle be sighted. This action may be to STOP the vehicle, MONITOR the movements of the vehicle pending advice or specialist support, or ASSESS the situation at the time of the sighting and make an informed decision whether to stop the vehicle, or for an alternative response to be taken.

The force originating the circulation must be prepared to provide assistance should the vehicle be stopped and the requested action taken in another force area. This could potentially be anywhere within England, Wales, Scotland, Northern Ireland, Guernsey, Jersey or the Isle of Man.” There is then content on levels of risk and response-

LOW For volume crime, priority investigations and RTC offences where a vehicle and/or occupants need to be traced (taking account of the circumstances where ACT is not to be used). MEDIUM For major, serious or complex investigations HIGH In the most serious of cases and in particular where life is at risk. This needs the authorisation of a Superintendent (or equivalent). In the event of a Superintendent (or equivalent) not being available an Inspector (or equivalent) can authorise, but this MUST be approved by a Superintendent (or equivalent) within 24 hours.

Hannah would clearly not have fallen into the low risk category (RTC is short for ‘road traffic collision). A vulnerable missing person is specifically listed as a ‘serious investigation’. If a medium or high ACT report is added, there must be one of three words to start the report indicating the activity that a force should undertake if there is a relevant ANPR activation. These words are – Stop, Monitor or Assess (as described in the above extract). ‘Monitor’ should only be used in exceptional circumstances, usually in circumstances when specialist resources are needed to stop the vehicle and occupants in a safe manor (e.g. should there be concerns about weapons in the vehicle). ‘Assess’ should only be used where there is ‘…credible information to indicate that the vehicle is being used to support criminal activity and that it is determined as reasonable and proportionate for the vehicle to be the subject of a national circulation.’ Neither ‘monitor’ nor ‘assess’ would be appropriate in Hannah’s case. ‘Stop’ would be the appropriate word and this should result in the following response- This should be used when the circulating force require officers to stop the vehicle and take action as described in the body of the report. Should an incident similar to Hannah’s happen today, the current ACT instructions should be followed and the ACT report noted with an instruction to STOP. Had this happened in 2016, Hannah’s vehicle would have been appropriately noted on the PNC and ANPR ACT systems and she would have been stopped, with there being clear instructions on what action the officers stopping her should have taken. I hope that this response is sufficient to deal with your concerns about the missing persons and ACT systems. NPCC will ensure that the issues apparent in Hannah’s case are raised through the

appropriate portfolio areas. This will help to ensure that, should a similar incident be investigated today, the correct actions and responses would happen.

Metropolitan Police Service Police / Law Enforcement

21 Apr 2023 PDF

Action Planned

The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. (AI summary)

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Dear Mr Ramsay

Deputy Assistant Commisioner Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A2JL

21 April 2023 I am the Deputy Assistant Commissioner for the Directorate of Professional Standards in the Metropolitan Police Service ("MPS"). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters ofconcern addressed to the MPS in your Report to Prevent Future Deaths dated the 13 February 2023. On behalf of the MPS may I first of all express my sincere condolences to the family .and friends of Hannah Warren, ourthough~s and sympathies are very much with them. At the conclusion ofthe inquest into Hannah's death six matters ofconcern were raised which are listed below. The matters raised all relate to the missing person investigation and the ACT report process within the ANPR system. Your report identified that whilst locating the car in which Hannah was travelling would have been the most effective way of locating Hannah, the MPS use of ANPR and specifically the ACT report process was insufficient in order to do so. As a result several opportunities to locate Hannah were missed. The cause of these failings appear to be due to a lack of organisational guidance and training around ANPR/ ACT report. This letter seeks to identify the issues arising from each of your concerns, the action being taken to ensure those concerns are addressed in order to prevent future deaths. The Coroner's "Matters of Concern'' The Prevention ofFuture Deaths report dated 13th February 2023 records: ]) The evidence was clear that the most effective means oflocating a missing person in Hannah 's position was to locate the vehicle in which it was assume_d she was travelling.

2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as "'medium" and the LOWstop priority instruction on ACT in relation to her vehicle.
3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols ofany kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, ifat all.
4) The preponderance ofthe evidence was that the LOWstop instruction was inappropriate in .this case, but I was not directed to any document or guidance tha~ would have assisted those responsible at the time for selecting the correct priority on the ACT.
5) I have seen no evidence ofany formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
6) This appears to be a national issue and is not related solely to the lack ofany formal guidance, training, or protocols within the MPS specifically. The MPS accepts that is should consider matters (1) to (5), our response to these matters of concern is as follows: ANPR and ACT reports.
i. The'·Automatic Number Plate Reader (ANPR) system is a national system which is used for a variety of vehiible related functions ranging from the management of car park tariffs to Road Traffic Act compliance. The system allows authorised bodies to retrieve vehicle and owner information from the Driver and Vehicle Licensing Agency (DVLA) for lawful purposes. Due to its national coverage, the ANPR system has been identified as a vital tool for police services when dealing with both crime and vulnerable persons where a vehicle is involved. The Action Report (ACT) process was developed by Police National Computer (PNC) Services to enable police forces to identify and provide real time location data for those vehicles where the police force requires some form ofaction to be taken should they come to notice. Adding an ACT report to a vehicle record will trigger the inclusion ofthat vehicle into the ANPR fast track pool. When to Use an ACT Report An ACT report should be used where it is reasonable and proportionate for that vehicle to-be subject of national circulation for the purpose ofappropriate action being taken should the vehicle come to notice, or when an intelligence marker normally circulated as an entry on a Vehicle of Interest (VOi) list contains warning signals which may compromise officer safety. There is an expectation when adding an ACT report that some form ofaction will be taken should the vehicle be sighted. This action may be to 'STOP' the vehicle, 'MONITOR' the movements ofthe vehicle pending advice or specialist support,

or 'ASSESS' the situation at the time ofthe sighting and make an informed decision whether to stop the vehicle, or for an alternative response to be taken. The police force originating the circulation must be prepared to provide assist,;mce should the vehicle be stopped and the requested action taken in another force area. This could potentially be anywhere within England, Wales, Scotland, Northern Ireland, Guernsey, Jersey or the Isle· ofMan. When entering an ACT report, as well as the action required, a risk assessment must be completed which highlights the level ofrisk or harm to the subject to assist the police force or officer taking action to take the appropriate response. These priority levels are set out in MPS policy (2019) as:
• High Priority - to be used in the most serious of cases and in particular where life is at risk.
• Medium Priority - to be used for major, serious or complex investigations
• Low Priority -.to be used for volume crime, priority investigations and road traffic offences where a vehicle and/or the occupants need to be traced. Missing Persons The College of Policing Missing Persons Authorised Professional Practice (APP) sets out clear processes and procedures for investigating these cases, risk assessments and risk management processes. The APP gives guidance to police forces regarding the way missing persons are risk assessed, which is High, Medium or Low. This risk assessment must be recorded on the relevant reporting system - the MPS use the Merlin system (Missing Persons & Related Linked Indices). The MPS notes the term 1 COMP ACT has been used in the Regulation 28 report, when referring to the missing person risk grading. COMP ACT is the missing person reporting system used by South Wales Police. The College of Policing's APP, provides the following guidance regarding missing person risk assessments:
• High risk - The risk of serious harm to the subject or the public is assessed as very likely.
• Medium risk - The risk of harm to the subject or the public is assessed as likely but not serious.
• Low risk- The risk of harm to the subject or the public is assessed as possible but minimal. Once the investigating officer completes the risk assessment, it must be confirmed by an officer of at least the rank of Inspector as soon as practicable. With regard to the circumstances, Hannah Warren was reported missing by her fiance and flatmate having gone missing from within the M~S. Hannah was graded and confirmed as a medium risk missing person on the MPS Medin system, this decision has not been questioned in the regulation 28 report. Investigating officers identified that the ANPR system would provide the greatest chance of ldcating

Hannah. However, when the ACT report was created in relation to Hannah's vehicle it did not appear to reflect the risk grading and/or concerns for Hannah's vulnerability. Based on the priority definitions, 'Low priority' for a vulnerable missing person would now not be appropriate. The ACT report was also lacking in sufficient detail to direct the identifying polic€ force or officer to take appropriate actiori. This meant that despite Hannah's vehicle activating a number of ANPR cameras several opportunities to intercept her were missed. The MPS were unable to provide to · HM Coroner details ofany training in place for Officers surrounding the creation of ACT reports. MPS action Following consultation with the College ofPolicing, it is accepted at the time ofHannah's death in 2016 there was no organisational guidance or training in place for officers around the ACT and REACT (Reaction - once the action has been taken) report process ofthe ANPR system. Within the MPS, there was no service level agreement (SLA) regarding governance and oversight ofthe content currently held within the ANPR system. In November 2022, the College ofPolicing published the Information and ComIIiunications Technology (ICT) learning document "ACT and ReACT reports on PNC". The document is a Home Office approved training tool aimed at frontline officers and supervisors, it details all aspects of the ACT process and responds to the failures and knowledge gaps identified during the inquest into Hannah's death. The MPS Learning and Development directorate are in the process of adapting this national guidance into a MPS training package, which will be delivered to all frontline officers digitally via the MPS Learning Management System. A key focus ofthe training will be to identify to all users the importance of ensuring the priority grading, information and request contained within an ACT report accurately reflects the risk presented by the subject or situation, and where this risk is documented (i.e. missing person report or crime report). The user must understand the link between the risk associated to the subject and the priority rating of the ACT report as this is crucial to.ensuring that the appropriate response is taken. The MPS commenced the training design and development in March 2023, it is anticipated the training will take up to 12 months from conception to completion. In addition to the requirement to train and develop all users of the ANPR system and ACT process, Hannah's death has highlighted the lack of governance and ownership of intelligence submitted in the ACT report process and held within the PNC.

To improve the accuracy of ACT report submissions, risk assessments and to ensure the ongoing management ofthe information held on the system, the MPS will shortly be introducing a new a Service Level Agreement (SLA). This requires all low and medium priority ACT reports to have been authorised by an officer of at least the rank ofinspector prior to submission ( currently only high priority reports require a superintendent's authority). In addition, all ACT reports must have nominated contact who is available 24hrs per day and suitably informed to provide updates and direction in the event of an activation. It will be the responsibility of the owning officer to review and remove entries from the system, ifthey are no longer required. The SLA is awaiting final approval, for publication in May 2023. Please do not hesitate to contact me should you have any queries. Yours ·sincerely,

Home Office Central Government

PDF

Noted

The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place. (AI summary)

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' Home Secretary Home Office 2 Marsham Street London SW1 P 4DF

His Majesty's Assistant Coroner Edward Ramsay

2.~ April 2023 Regulation 28 report: Hannah Warren (ref: 127458) Thank you for your email of 14 February. As requested, I am writing to formally respond to your report pursuant to the duty in paragraph 7(2) of Schedule 5 to the Coroners and Justice Act 2009 and pursuant to the requirements in regulation 29 of The Coroners (Investigations) Regulations 2013. This report relates to the circumstances surrounding the death of Hannah Warren in February 2016. At the outset, I wish to express my most sincere condolences to Hannah's loved ones for the distress they must have experienced following Hannah's death. Your report raises a number of concerns about the guidance and training for police officers investigating missing person reports; specifically, the use of the action report (ACT) in relation to Hannah's vehicle. The police investigation of a missing person report is an operational decision for individual police forces. The standards for these investigations for all forces in England and Wales are set by the College of Policing (henceforth 'the College'} through their Authorised Professional Practice (APP). The College also issues guidance for police forces, including instructions on the use of ACT and REACT reports on PNC, the most recent version was published in November 2022. The College is independent of Government; its role is to set high professional standards for policing; sharing what works best; acting as the national voice of policing; and ensuring police training and ethics is of the highest possible quality. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, for the purposes of this response, my officials have consulted the College, the Metropolitan Police and the National Police Chiefs Council (NPCC) to seek assurance that the appropriate guidance is in place which addresses the concerns that you have raised.

I am satisfied by the College that there is current police guidance on this matter which is readily available to forces; and clearly sets out the actions police officers should take were these circumstances to arise again. Specifically, the guidance states that missing persons fall into the category of 'serious incidents' and as such, at a minimum, a medium priority ACT report should have been put in place. The response from the College will set out further detail on the use of the ACT guidance. Thank you for bringing this matter to my attention. My Ministers and I are committed to continuing to work with police forces in England and Wales through the College and NPCC to ensure that missing, vulnerable people are protected from harm. I hope this response assures you, and Hannah's family and friends, that your findings are being given the appropriate attention in order to ensure that the proper processes are followed should these circumstances arise in future missing persons investigations. Rt Hon Suella Braverman KC MP

Report sections

Investigation and inquest

On 15 FEBRUARY 2016 the Senior Coroner commenced an investigation into the death of HANNAH WARREN aged 28 (hereafter “Hannah”). The investigation concluded at the end of the inquest held between 16-26 JANUARY 2023. The conclusion of the inquest jury was that Hannah died as a result of 1(a) drowning 1(b) head injury, and they returned a narrative conclusion in the following terms:

Circumstances of the death

(1) In the evening of 3 February 2016 Hannah was reported missing by her flat mate and fiancé. The report was made to the MPS. It appeared Hannah had left London in her motorcar shortly after 11am that morning and had not been spoken to since around 10.30am. (2) It was reported that she had been acting out of character expressing delusional thoughts and ideas, specifically that she “hacked into a computer” and the “government were after her”. (3) Hannah’s case was considered by the Duty Inspector at Brixton police station towards the end of his shift that evening. He assessed Hannah as “medium risk”

using the COMPACT risk assessment tool. (4) A LOW stop ACT was placed on Hannah’s vehicle on the Police National Computer by the investigating Police Constable. There was no specific instruction to place a Low ACT (as opposed to a Medium / High stop ACT) and no discussion about which priority to place on the said ACT. The available evidence established that ‘LOW’ would probably have been placed on the ACT by default. (5) Meanwhile Hannah had travelled in her vehicle down to Brighton, along the south coast as far as Exeter, and then north towards Weston Super Mare, before rejoining the M5. (6) A call from Avon and Somerset Police into the MPS shortly after 10.00pm notified them of an ANPR activation for Hannah’s vehicle inbound to Weston Super Mare. Avon and Somerset requested further details from the MPS. (7) A second call just over one hour later notified the MPS that the vehicle was heading back out towards the motorway and again requested further details from the MPS. (8) A third call from Gwent Police into the MPS shortly before 02.45am on 4 February 2016 made a similar request information in relation to the ACT instruction. (9) Hannah’s journey generated no fewer than 27 activations on the ANPR system, the last at about 03.25am in Margam, Port Talbot. (10)The ANPR Bureau were not contacted by the MPS during this time. (11)At around 03.25am Hannah entered the Port Talbot harbour site via a private road. Her body was found in the lock entrance to the harbour shortly after 9am on 4 February 2016 and her car located underwater in the harbour itself by South Wales Police divers. (12)During the inquest the MPS accepted five shortcomings with respect to the missing person investigation for Hannah. These shortcomings were recorded in Box 3 of the Record of Inquest. They were: “(1) On the overnight response team shift, which received the handover from Inspector , there was a lack of action taken to progress the missing person investigation. (2) There was insufficient and insufficiently timely use of the ANPR Bureau by officers investigating the missing person investigation. (3) There was a failure to contact Hannah’s family, in particular to check whether Hannah had any known family or friends in the West of England. (4) There was shortcoming in the flow of communication from the calls received into the Metropolitan Police made by regional Police forces to the response team investigating the missing person investigation. (5) The ACT placed on the Police National Computer directing a stop of the vehicle driven by Hannah was marked as a Low grade, when it could have been marked as a Medium grade.”

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