Paul Kalnins

Dear Ms Persaud, write on behalf of the Metropolitan Police Service in response to your Regulation 28 report to prevent future deaths, dated 15th July 2015. This was prepared following the inquest into the death of Pauls Ricards Kalnins, heard on 9th and 1Oth July 2015. Mr Kalnins was initially reported as a missing person; seen alive by police on Sth 2014 and subsequently found hanging in a shed to rear of Foresters Apartments, Barking Essex on Gth July 2014. You will recall that the finding of the inquest was suicide. Matters of Concern In your 'Matters of Concern' comments you reviewed communication officer's evidence of his unfamiliarity with the system, its reported complexity, and the issue of refresher training, before concluding:
1."/ consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future_ 2 "Mandatory refresher training for communications officers may also reduce the risk: MPS Response Preface In drafting a response to these points, subject area experts have been consulted, principally: Ian Cox and Richard Gittings, of HQ Digital Policing, under the ultimate command of Commander Alison Newcomb, Business lead owner for the Merlin database system; Chief Inspector Paul OHerlihy, Chief Inspector -Professional Standards & Continuous Improvement Standards & Capability Unit; Central Communications Command (MET CC), responsible for communications staff. Your July the the

Dates, relevant parties, and communications have, where possible, been confirmed by reference to emails, meeting minutes, published policies, intranet communications or other documents_ The following is based on a review of such documents. The above parties have in turn, reviewed this response have not had sight of transcripts of any oral evidence from the inquest itself so in the event of any variance between these reported facts and evidence you know to have been presented during the inquest itself;, of course defer to your greater knowledge. Response Concern #1: Highlighting Risks on the front screen of Merlin (states that if information is correctly input onto the system in the first place, the suggested functionality is already present on the system, and would result in a red warning triangle being prominently visible on the top right of every page of the database Clicking on this triangle takes one directly to the relevant warning text: An internal briefing document with screen shots taken Mr Kalnins' real Merlin record has been prepared to illustrate this, but as this contains sensitive personal data which should not be circulated to third parties without permission, It has not been included here If you wish to have sight of this document;, please advise, and we will facilitate this separately. The document has been viewed by Detective Sergeant my Organisational Learning Manager and she confirms that it illustrates the process by which the Warning Signal alert is invoked when creating or updating a record, by selecting from clickable drop down list of Warning Signals, which can be used to highlight issues explored more discursively in the free text 'DETS' entries As Mr Gittings states at #6 of his briefing note: "This addresses the recommendations of the Coroner, but as with any IT system, it depends on users inputting information correctly. In short; individual operator error might be said to be an issue in this aspect of the case, but that error principally in the omission of the original inputting officer; in failing to select the appropriate warning flag to accompany and highlight the free text information found in the relevant 'DETS' Had an appropriate flag been selected at the of creation Mental' [health], 'Suicidal' and 'Self Harm' are three examples of the selection available, from longer drop down list then the front page, and every other page of the report viewed by the communications officer would have born the unmistakeable and very visible red triangle 'road sign' graphic icon containing an exclamation mark in the top right corner of every page of the record, offering a direct; clickable link to the relevant information: In relation to this area of concern, the Metropolitan Police Service does not intend to make changes to Merlin database because the functionality identified already exists. However , the importance of this functionality will be part of the training that is set out below, with an intended completion date of 31 March 2016. Response Concern #2: Refresher Training It nevertheless remains true that an operator who was more experienced with the Merlin database than the communications officer in this case, may have thought to check the DETs entries in case any vital information was missing: entry. from any point Iay entry: point entry the

This, and the evidence given at inquest by both the communications officer and the DPS investigator_ regarding the relative lack of 'user friendliness' in the Merlin system, suggests that more could be done to improve the knowledge of our communications staff in regards to the system: This need has become more pressing since January this year; when Merlin was adapted to provide the central repository of non-criminal information about adult 'Vulnerable Persons' coming to the notice of police. This includes information regarding police knowledge of a person's previous mental health history_ With this in mind and in direct response to this recommendation, Chief Inspector O'Herlihy contacted all line managers for the affected staff as set out below on the 12th August 2015 This was on the instructions of Operations Superintendent at MET CC "The recommendation for Met CC was to accept that mandatory refresher training for communications officers on the Merlin database may reduce the risk fully accepted this and asked that a plan be developed to deliver this training: The training is delivered via [computer based training] NCALT over three modules and takes a couple of hours_ .a completion date of 31st March 2016 has set to allow for a final compliance check at the yearly Performance Development Review point. have suggested that priority should be given to the staff not trained, with the opportunity to refresh understanding for staff who are can | ask you to ensure that line managers are aware of this requirement and that training is monitored at each centre to ensure 100% compliance, by 31st March 2016. The intention therefore is that by 31st March 2016, all current staff at MET CC have had recent refresher training; incorporating both the importance of the 'red flag' marker and the possibility that there may be important detail contained in the incident reports not flagged by it; The completion of this training will be checked at an individuals annual performance review to ensure compliance. In Conclusion trust the measures taken above reassure you that we have responded and promptly to the points you have raised arising from this tragic incident: Yburs sincerely, FionaltaMor Deputy Assistant Commissioner been will fully loftov