Source · Prevention of Future Deaths

Arsema Dawit

Ref: 2014-0442 Date: 13 Oct 2014 Coroner: Andrew Harris Area: London (Inner South) Responses identified: 1 / 1 View PDF

Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.

Date 13 Oct 2014
56-day deadline 8 Dec 2014 est.
Responses identified 1 of 1
Police related deaths

Coroner's concerns

AI summary
Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
View full coroner's concerns
It is clear that there was a significant time between the report to the police station and her death, and that the investigation was hampered by the deceased's subsequent denial at her school, of attending the police station. It is also clear that the period of investigation coincided with changes in police systems and staffing pressures_ Nevertheless, In the circumstances it is my statutory to report to you_ , (1) The senior reception officer premalurely classified the offence; failed to reclassify it when the full detalls were known at the end of her interviews and entered a misleading entry on the CRIS that the Inspector whom she had briefly asked a question, had been informed of incident; which he had not; but others assumed he had been. He was clear that had he known the full account of the incident; he would have required further steps to be taken at the outset. Is the SRO appropriate to complete the CRIS in such a case and is the system of recording and reviewing the entered principal offence now understood by reception officers? "Her There duty the

(2) The court was told that most serious crime reported should be the principal offence; but the threat to kill was not entered as the principle offence, when the case was reviewed by senior supervising officers, nor was a linked crime report made. The entry of the second Inspector was insufficient to properly inform others of his decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who did not question the appropriateness of the principal offence, despite contrary evidence: It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations.

(3) The action plans that were adopted appeared to have been supervised sub-optimally by Detective Sergeants. It is not clear whether these were individual weaknesses or reflect a wider weakness in the role of supervisors.

(4) According to MPS Standard Operating Procedures at the time, the offence could not have been reported as domestic violence as those involved were not adult and was outside the remit of the child abuse investigation team. There appeared to be a gap, which might mean inappropriate or insufficient investigation could be carried out; (5) There appeared to be some reluctance to use the interpreting service, s0 that the mother was never interviewed:

Responses

1 respondent
Metropolitan Police Service Police / Law Enforcement
13 Oct 2014 PDF
Action Taken

The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services. (AI summary)

View full response
Dear Hamr write in response to your Coroners Report to Prevent Future Deaths, dated 13th October 2014, following the Article 2 inquest opened by you in November 2012 into the death of Arsema Dawlt; 15, on the 2nd of June 2008. The conclusion of the inquest, delivered by the jury on 2eth of September 2014 was unlawiul killing of Miss Dawit. Although the jury did not find the role of pollce In the incident had contributed more than minimally to the circumstances of the death; in their narrative accompanying their verdict they did draw critical attention to a number of aspects of the pollce handling of the situation: These included limitations In the taking of an initial report made by Miss Dawit of abusive behaviour towards her by her later killer, the recording of the principal offence as Actual Bodily Harm rather than as a Threat to Kill; a subsequent investigation 'inadequate' to a threat to kill reported by Miss Dawit in her initial approach to police; a lack of timely investigation; poor communication with the family; and minimal supervision of the case. The jury additionally noted the deceased's later unwillingness to assist which hampered the police investigation of the initial incident. You identified five matters of concern, which paraphrase respond to here. My comments have been informed by discussion with subject-area specialists. 1: Initial classification by tho SRO You pointed out that initial classlfication of the offence by the civilian Station Reception Officer (a role now occupied by broadened function of 'PAO' -Public Access Officer) was incorrect; and that an entry written by this staff member on Ihe Crime Report Information System ('CRIS') implied that a brief question asked of an Inspector during the taking of the initial report amounted to informing him of the incident, therefore that a senior police officer had reviewed the facts_ Thls was not the case . You asked; "Is the SRO appropriate to complete the CRIS in such a case, and is the system of recording and reviewing the entered principal offence now understood by reception officers?" Response: A decision was taken by Management Board in 2007 that the Station Reception Officer (SRO) role would cease t0 exist with effect from 31
2008. Initially, those staff recrulted to the revised position after this date were called 'Station Police Community Support Officers' ('SPCSOs'), who were part of the Police Community Support Officer family. Patrolling had not formerly been parf of the remit of the SRO, and s0 20/1 1/2014

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these officers received the standard training in respect of the patrol and other ordinary duties of the PCSO, together with training on the subjects of criminal investigation; victim care, missing persons investigation, as well as a number of other, front counter specific tasks. Subsequently, under Territorial Policing Development's Public Access Project; the MPS again revised the definition, replacing it on the Ist November 2012 with the still-current role of Public Access Officer (PAO): Though there Is now no patrol element to the role, the new post is notably broader in remit than both the SRO and the SPCSO which preceded it. PAOs are now trained for and work exclusively as specialists within the front counter environment; Their responsibilities and (raining have been extended to include statement taking; the initial recording of complaints against police; and the administering of an appointments system current PAO training course was designed centrally in conjunction with MPS training command, known as 'Met Training' and Is delivered by dedicated trainers from Met Training: It takes place over 13 days and is mandatory requirement before a new staff member can take up a post within the MPS. Attendance on and successful completion of the course is monitored by line managers on the trainee's home Borough Operational Command Unit (BOCU'). The curriculum of the course covers all aspects of Ihe role of staffing a front office or other public access point Topics covered most relevant to the Dawit case include: Customer service Including listening and questloning skills, and awareness of how to access the 24/7 'Language Line' instantaneous ielephone translation service now available at every of public contact . (for more on translation services, see below): Primary investigation Including every stage of the initial investigation that would be required in every crime - captured in the concept of 'Research, record, retain and refer' The 'refer' lessons in particular are dedicated to ensuring that the correct person is appraised in order to take the investigation forward and manage any associated risk clearly addressing the initial oversight highlighted by the jury in the present case. Critical Incidents including how to recognise one, what to do when they occur, who t0 inform_ Domestic Abuse Total Victim Care It is worthy of note that these lessons are very similar to those given to a PC recruit: Every member of our frontline engagement with the public, whether officers or staff; thus begin the first day of their appolntment to a station with a similar set of decision making tools, and are encouraged to think of themselves as 'initial investigators' from the moment they begin taking any report Where a number of possible offences could describe a sequence of events prompting a report to police, the rule is always has been that the most serious should be the one under which the report is initially classified: It is acknowledged that an early oversight in the Dawit case was in to Idenfify a 'threat to kill' , treated as background to a lesser, but more evident offence of Actual Bodily Harm. Whilst it of course will always be the case that individuals may make questionable decisiong, (which our supervisory processes are designed to identify and rectify, see below,) there is no inherent reason why: given the preparation we give our staff, and the business processes that we have Instituted, that a report taken by a PAO should not now be as detailed and investigatively useful as one taken by any officer. In short, in answer to your question; "Is the SRO (PAO) appropriate to complete the CRIS in such a case and is the system of recording and reviewing Ihe entered principal offence now understood by reception officers?" , notwithstanding (he particular facts in the Dawit case, we would answer 'Yes_ Underlying the whole of the input received by PAOs is the National Decision Model, an Association of Chief Police Officers-endorsed tool now employed by all forces to provide their officers and staff with a baseline for engaging with any issue requiring an operational decision of some sort, The National Decision Model 'NDM') is designed to be suitable for all decisions _ It can be applied alter spontaneous incidents or before planned operations, by an individual or teams of people, and to both operational and non-operational situations_ Decision makers can use it to structure a rationale of what they did during an incident and why: Managers others can use it to review decisions and actions taken: The inherent flexibility of the NDM means that it can easily be adapted for any task within policing: In every case, the decision making model stays the same, but users decide for themselves what questlons and considerations they should apply at each stage person addressing a decislon (e.g: "What do do with this allegation?") is therefore expected to begin by asking themselves: Is what I'm considering here consistent with our Statement of Mission and Values? (i.e. decisions must reflect the police duty to act with integrity, be willing to take risks and protect the human rights of all, What would the Police Service expect of me in this situation? 20/11/2014

The point and and failing and Any

What would victim(s), the affected community and the wider public expect of me in this situation? Having considered this, the NDM then directs any decision maker to consider complementary areas to inform their decision: information gathering, assessment of risk, consideration of powers policies, identification of options, then finally, action and review do not propose to replicate the guidance offered under all these stages in detail here, but the first two of these perhaps illustrate how the questioning stance the NDM encourages users to adopt should have potentially informed the decision making process of the Station Reception Officer in the Dawit case, had it been available at the time: "Stage 1: INFORMATION Gather Information and Intelligence During this stage the decision maker defines the situation (ie, defines what is happening or has happened) and clarifies matters relating to any initial information and intelligence. What is happening? What do know s0 far? What further information (or intelligence) do wantneed? Stage 2: ASSESSMENT Assess Threat Risk and Develop a Working Strategy This stage involves assessing the situation, including any speclfic threat; the risk Of harm and the potential for benefits_ Do | need to take action immediately? Do need to seek more information? What could go wrong? (and what could go well?) How probable is the risk of harm? How serlous would it be? Is that level of risk acceptable? Is this a situation for the police alone to deal with? Am the appropriate person to deal with this? (ry emphasis ) As can be seen a person following the thought process encouraged by the model would automatically be called upon to risk assess any threat made, to identify 'gaps' (such as the communication issues highlighted by the jury), and to seek appropriate guidance. In support of such better decision making, a further innovation since 2008 has been the refashioning of our sometimes unwieldy policies and procedures into a series of user-friendly 'toolkits' available 24 hours a seven days a week; from any MPS computer workstation. These are designed to be clear, concise guides, 'Frequently Asked Questions' and checklists which can support any frontline officer or staff member before, during; or after dealing with any situation which they may be unfamiliar with. For example, Iinks to an easy to follow chart of necessary actions setting out how a 'Threat To Life' should be recorded, reported, and progressed Is now included in a bespoke online reference guide, the Reception Services Manual; for use by Public Access staff, This manual contains, inter alia, specific guidance on how to deal with: Threats to life" Critical Incidents Domestic Abuse Vulnerable Adults All of which would have been of potential relevance in the present case.
*Please note 'threats to Iife' , whilst may well Incorporate instances of the criminal offence of Threats To Kill; contrary to 5.16 of the Offences Against The Person Act 1861 ( A person who without lawful excuse makes to another a threat; intending that that other would fear it would be carried out; to kill that other or a third person shall be guilty of an offence"), more specifically describes the broader issue f responding to credible intelligence being received from any source that a life is at risk, in line with National Guidelines on the topic_ Such intelligence may at the point of receipt not always amount to a clearly identlfied offender, victim , or offence. (Indeed, in the Dawit case, although the name of the 'boyfriend' was glven, it was given incorrectly and no other identifying detail
i.e. DOB or address was provided with it. Consequently, an early stage of the risk assessment of any such threat, now clearly set out in the 'Toolkit' 20/11/2014

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flowchart referred to above, Is to decide ifan allegation of a substantive offence of a threat to kill has already been made out; If s0, then the investigation of the alleged crime; once recognised as such, will automatically attract an enhanced ievel of threat assessment from a suitably qualified investigating olficer; the interdiction of the threat will proceed a8 for any other allegation of serious crime (escalated to CID to deal, etcetera) . Equally, if more intelligence needs to be done to substantiate a possible rlsk, steps taken to warn or protect possible targets and so then there is now a clear management process in place to direct these efforts. Introduced MPS Wide in 2012, we call this 'Grip Pace The overarching rationale for Grip and Pace, developed as part of the Met Change programme; is to ensure that there is an effective 24/7 police response connecting and driving business and service commitments, replicated on every borough In each case this takes the form of a single CO-ordinating the 'Grip and Pace Centre' which has access to oversighf of all the critical personnel and resources (intelligence systems; equipment; vehicles) required. This local co-ordinated resource tasking deployment system is focused on the concepts of possible 'harm' presented by individuals and situations, 'opporlunilies' t0 intervene in these, 'threats' to our ability to intervene. These lactors are dynamically assessed by experienced 'Harm, Opportunily, Threat' (HOT') supervisors Their assessments then drive tasking declsions. This process can be summed up as having a "Grip" on Borough resources and responding to the developing "Pace" of the day, with the intention of identifying short term and longer term crime patterns and trends, and ensuring We have the right people in the right places at the right times to deal with incidents as they arise. The model depends for its' effectiveness on three 'Pacesetter' review meetings conducted at regular intervals throughout the 24 hour day; Involving a number of co-located personnel deployed to specific roles: The on-duty Senior Leadership Team lead takes responsibility for the deployment plan and provides 'Real Time' leadership on daily activity by tasking available assets to support Intelllgence-led policing; The HOT supervisor provides continuous assessment of potential Harm t0 individuals or situations identifled in information as it comes in, Opportunities (to intervene) and Threats (Intelligence on the sources of the risk), responding immediately to changing circumstances. This is achieved through constant monitoring of Computer Aided Despatch system which initiates the response to calls, and documents their resolution, supported by our crime recording system, CRIS, and our intelligence systems IIP (Integrated Intelligence Platfom) and MERLIN (Missing Enquiries and Relevant LInks Indices): By locating oversight of these functions with a single; named HOT supervisor; this achieves a dynamic, accountable 'ownershlp' of risk in any evolving situation. Meanwhile, Fugitive Management identifies, traces and monitors wanted missing offenders for incidents, and relays progress to the HOT supervisor and SLT fast-time resource deployment; report of a 'threat to kill' received now recognlsed as such would therefore immediately trigger a comprehensive intelligence and threat assessment, and response. Collectively, the intention is to ensure that this and Pace team, all operating from a single location on each Borough know where crimes are happening; who the suspects might be and what resources we can deploy to prevent or apprehend them, from first report to resolution of the incident. How this might into a report taken at the front counter is set out below. 2: Initial Classification issue You wrote: "The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence, when the case was reviewed by senior supervising officers, nor was a linked crime report made_ The entry of the second Inspector was insufficient to properly inform others of his decislons; Two inspectors were involved and that gave false reassurance to more junior officers, who then did not question the appropriateness of the principal offence, despite contrary evidence: It was not clear whether this was series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations Response: As above; we have acknowledged the Initlal error made in failing to classify the CRIS report under the most serious offence alleged, the threats to kill, and accept that such initial classification errors by the original submitting officer or staff member, on occasion compounded by subsequent oversights by supervisory officers may; despite the Iraining and support we have already discussed, still ccur_ It is important to realise however that the initial recording officer does not confirm the classification (and thereby, il's onward route through risk assessment; investigation; etcetera): Nor, since 2012, do local investigators or their managers: Conflrmatlon of that initial classification was then and remains today a supervisory function. However; the 20/11/2014

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significant improvement in our business processes since 2008 has been the Introduction in 2012 of a centralised, independent quality assurance layer which assumes responsibility for the conflrmation of initial classification for all reported crimes MPS wide. This centralised independence provides an opportunity to correct local errors of the type which occurred in the inilial recording of Miss Dawit's allegatlon. The supervision is provided by the Crime Assessment Unit (CAU), comprising three teams of experienced detective and uniformed officers and staff; each headed up by an inspector CAU run a series of automated searches to ensure that any reports lacking the necessary classification confirmation undertaken by them are reviewed and progressed appropriately: Their expertise and familiarity with Home Office Counting Rules and National Crime Recording Standards ensures a high degree of ethical, corporate, consistency in the confirmation of any initial classification: A CAU team will review, confirm, and If necessary amend classifications This is undertaken against a national target of correct classifications being confirmed as soon as possible, and, exceptionally; within an outermost limit of 72 hours. Inspector of Team 1 CAU was asked what would happen in the event of the initial Dawit CRIS appearing today: He is confident that the team's review function would pick Up the threats to kill 'hidden' in the details section of the original report: The crime would therefore have been reclassified correctly at an early stage, opening tho way to appropriate risk assessment, enhanced intelligence checks, and early investigative action. The CAU team enable this by redirecting the reporl back to the submitting Borough's 'Grip and Pace' function; as discussed above, where It would fall to the 'HOT Supervisor' to conduct a minimum full five year intelligence checks on victim and suspect; and to take any other necessary local action to ensure that the crime was triaged to appropriate local resources to actively progress the investigation: 3; Supervision of Action Plans You wrote: "The action plans that were adopted appeared to have been supervised sub-optimally by Detective Sergeants. It is not clear whether these were individual weaknesses or reflect a wider weakness in the role of supervisors_ Again, we acknowledge that individual officers may make poor decisions: Mitigating this risk requires recruiting; training; and developing the right people; providing them with the support systems to enable them Io operate effectively; and building corrective procedures into way we underlake ordinary business. The aims of any robust Investigative process should therefore incorporate means to Iimit the scope of any poor decisions to cause harm to the investigation, and to enable the prompt identification and rectification of any shortcomings, through routine activities such as regular review periods, oversight by more senlor line managers, SO on Since 2008, considerable work has been underlaken nationally and wilhin the MPS on these fronts, beginning with a number of significant changes nationally and within the MPS in the tralning and support of all newly promoted and serving uniformed and detective officers For example, all successful candidates in constable to sergeant promotion processes, whether uniformed or detective, are now required to take a number of National Centre for Applied Learning Technologies (NCALT' self-taught computer based training modules on topics such as the aforementioned National Decision Model; before attendance at a mandatory 'new sergeants" course. Between 2010 and 2014,this course ran for 5 days. Emphasised, amongst other topics _ are Ihe concepts of intrusive supervision; of being able to evidence effective supervision through documenting action plans , decision maklng; delegating processes in entries on official reports, decision logs, and so on. This course was enhanced and extended to seven days in May 2014. The Inltial classroom element is also now complemented by a six- month probationary period, during which; whilst all newly promoted sergeants are underlaking their new role, they are expected to successfully complete a workbook of evidence showing how they address a range of typical supervisory tasks. These requirements are common to all newly promoted sergeants_ Work is also in hand to further develop continuous professional development for all in-post officers and staff, through the 'Leading for London' programme: To be piloted across seven pilot sites early in 2015, (Westminster, Haringey, Southwark; Met Prosecutions, SCO19 Specialist Firearms, SCO17 Sexual Offences, Exploitation and Child Abuse and SO14 Royalty Protection) with the eventual aim of a London- wide roll-out; this is a practical skills-based 'roadmap' available to all, For the first time in one clearly understandable intranet 'document' it will set out the knowledge; skills or behaviours one will be required to evidence at each stage of a career within the MPS , and the different development modules one will need to 20/11/2014

The the and and and

supporl this progress over time. It highlights the leadership skills officers and staff at any rank or grade need to meet current challenges and deliver the best possible policing for London: The core identified skills are; Valuing and promoting diversity and inclusion self-aware and understanding your impact on others Empowering others Encouraging challenge and seeking feedback Delivering change through collaborative working and problem solving across the Met and other partners; Adapting your approach to suit the situation and context In addition to all of the above, Detective candidates are additionally required to pass an internal selection process for the role; be recommended by their current line management for it;, then to evidence their practical competencies in a rigorous, skills-based Detective Development Programme, followed finally by a knowledge-based test; the National Investigators Examination: Once In post, any detective of any rank in an active Investigative role Is thereafter required to provide evidence in their annual performance review of their continuing professional development Within the MPS all supervising detective sergeants newly promoted under this process, or detective sergeants who qualified under earlier legacy processes_ are also further required to attend at least one further , practically-based investigative skills course, the Initial Management of Serious Crime. learning objective on this course is to; "Explain the importance of malntaining a record of decisions giving direction to an enquiry and prioritising team activity: The centrality of clear investigation plans and logs of actions undertaken Is therefore now fundamental to the MPS undersianding of the role of any detective supervisor: The 'Toolkits' concept we have already touched on above is also relevant here. In support of any supervisors drafting of a bespoke action plan for a crime, the MPS now has a set of aide memoire for use by all primary and secondary investigators and supervisors of crime, directing their attention to relevant factors. Based around a core toolkit; the 'General Investigation of Crime' , supporting checklists cover in greater detail some of the Issues to consider when investigating certain common offence types Of potential relevance in the Dawit case would have been the enhanced guidance available in the Domestic Abuse toolkit' directing the investigator to consider use of interpretation services, Risk Assessment; and where relevant; the Vulnerability Assessment Framework. For example, the MPS defines vulnerability as something which: .may result from an environmental or individuals circumstance or behaviour, indicating that there may be a risk to that person or another. Those who come to notice of the police as vulnerable will require an appropriate safeguarding response, Additional factors to vulnerabllity may include Mental Health, Disability, Age or illness and should include an appropriate multi-agency intervention; especlally In cases of repeat victimisation.' emphasis] Here, Miss Dawits youth, in relation to the (initially reported '30 year old' , In fact 21 year old) suspect was a risk factor; as was her status as a child of 14, which would engage another toolkit, on child safeguarding: Both of these factors her youth, and her potential vulnerability require a 'Merlin' database entry to be created, and indeed this was done in her case. A Merlin entry provides the gateway to enhanced intelligence checks on the family details_ to inter-agency problem-solving CO-operation with Social Services, Health, and Education: A new development in this area since 2008 is the establishment of the 'Multi Agency Safeguarding Hub' , (MASH') , which co-locates safeguarding agencies and their data into a secure assessment, research and decision making unlt which receives all notifications relating to safeguarding and child welfare from any source in each Local Authority area. These are in the process of being extended to include vulnerable adults, adding additional value and providing a hub for activity around families. By a MASH providing a fire walled Though see Iha issue wilh nalional delinilions discussod at point #4 below 20/11/2014

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environment each partner agency is assured of the confidentiality of the process and that any resultant dissemination of partner agency information in a safeguarding intervention (particularly important for police and health) is proportionate. The model also allows for processes regarding missing people, domestic abuse, chlld exploitation and others to be included. These hubs review all Merlin reports, risk assess them , where appropriate convene multi agency problem solving meetings, to which relevant third parties, such as local investigator dealing with a case Involving a MASH subject, may be invited. The MASH also creates action plans for the partners involved, refers these, and maintains a corporate memory of engagement with Ihe Merlin subjects. Should circumstances similar to those In Arsema's case occur now; it would therefore fall to the MASH to review the associated Merlin; to consult with the partner agencies, if any issues additional to the 'headline' crime were to be noted such as the history of harassment, or the apparent age dlscrepancy to convene a meeting of partner agencies to deal with the issue. In effect; if a police focus on a future Miss Dawit would be as the victim of a crime; the MASH focus would be on her as a chlld currently subject to adverse circumstances, thus affording a further, broader quality-assuring 'lens' through which the totality of the situation would be viewed, and initial oversights caught, rectlfied, and referred back to the relevant department within the police or other agency to deal. 4: Remit issues wrote: "According to the MPS Standard Operating Procedures at the time, the offence could not have been reported as domestic violence as those involved were not adult and was outside the remit of the child abuse investigation team: There appeared to be a gap, which might mean inappropriate or insufficient investigation could be carried out. Response 'Flagging' crime report (by adding a code to a page on the computerised CRIS report) is the mechanism by which crimes are brought to the attention of specialist investigative departments. For the avoidance of doubt; difficulties in the correct 'flagging' of crimes for these units due to remit issues are no bar to the initial reporting of the crime, nor to it's subsequent investigation by a competent investigator. Such difficulties however may inadvertently limit access to the additional expertlse that specialist units provide. It is important t0 realise however, that 'generalist' investigators dealing in lieu of specialists will still be officers trained to a suitable level for the task In line with the natlonal standards set by the College of Policing the Association of Chief Police Officers' 'Professionalising Investigation Programme' (PIP) , investigative tasks are graded by Level, and assigned to appropriately trained officers who have demonstrated their competence t0 deal at the relevant level through an 'evidence-based system focused upon intrusive assessment of practical ability and knowledge'. Within PIP , the three levels are: Level 1 ~ Priority and Volume Investigations includes all officers whose role might involve interviewing victims, witnesses or suspects. This includes patrol police constables supervisors_ Level 2 _ Serious and Complex Investigations This includes officers and CID supervisors, and lead traffic officers involved in fatal collision investigation. Level 3 Senior Investigating Officers lead investigators in cases of homicide, series stranger rape, kidnap or crimes of complexity: Within the MPS it was agreed that this would be restricted to Homicide SIO's within SC801, 8, 17 and 8015. It is impossible to be prescriptive in relation to which crimes are Level 1 and those whlch are Level 2, though It is understood that Level 1, 'the Investigation of volume crime' , is typically considered appropriate to be investigated by patrol constables and supervisors_ Some instances of Actual Bodily Harm, the substantive offence initially identified in the Dawit case, could fall into this category: Equally, there is no all- encompassing definition of what constitutes a 'serious or complex investigation' _ but there is an understanding within the service of the types of investlgation that fit this category, based on experience, and the likely skills and resource commitment required to achieve successful resolutions_ Threats To Kill; the most serious offence reported to police in the Dawit case, would be a Level 2 offence, requiring a suitably qualified investigator to deal. In practice, Level 2 crimes are primarily investigated by Detective officers. 20/11/2014

and and You and and CID

In the Dawit case, the matter was referred to a Detective officer to deal, albeit within the 'generalist' main office of CID, and with an (incorrect) assumptlon that the substantive offence involved was Actual Bodily Harm , Despite decisions made by some individuals in the case therefore; at the level of process, the remit issue highlighted in Dawit did not impinge on the skills level of investigator allocated to deal, Clearly, though; specialist units do 'add value' through their greater knowledge and experience of certain crime types, and it is here the remit issue was relevant. Resolution of this, however, lies ultimately beyond the reach of the MPS to address directly, as will now explain: Within the Criminal Investigation Department the remits of the specialist investigation units dealing with Domestic Abuse (the Community Safety Units) and with offences against children (the Child Abuse Investigation Teams) are based on a number of factors. Pre-eminent amongst these are the national definitions for the relevant crime types, which are set by the Home Office, and are not in the gift of the police to directly aller; although of course issues of concern can be raised with the Home Office via representations to the National ACPO leads in the relevant area In relation to 'Domestic Abuse' , the Home Office definition operative at the time of the incident set a lowest age limit of 18 for victims, This definition was revised in 2013, and currently defines domestic abuse as; any incident or pattern of incidents of controlling, coercive, threatening behaviour; violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality: abuse can encompass, but is not limited to the following types of abuse: psychological physical sexual financial emotional" It will be noted that although the age limit has been dropped; this would still exclude Miss Dawit (aged 14 at the time of the report and 15 at the time of her murder) from inclusion within the standard CSU remlt, as would her denials that there was any aspect of intimacy in her relationship with] and the fact that he was not part of her group. At 14, Miss Dawit was considered a child. However; Ihe current remit of the Child Abuse Investlgation Team is to deal wlth abuse of children In the following contexts: Intra-familial abuse (as opposed to a stranger attack) defined as "within the family and extended family defined as aunts; uncles; cousins; siblings including step, fostered, half brother and sister; grandparents, step grandparents, mothers or fathers and can include long term partners but must be established relationship" _ Professional abuse working in a child focused environment who abuses their paid position e-g: teachers; sporls coaches; youth workers; ministers; caretaker of a school; school cleaner; prison staff; Other carers who act as a carer with some responsibility for the child at tha time of the offence
e.g. babysitters; voluntary groups Iike scouting, unpaid sports coaches, close personal family friends. This list is not exhaustive and consideration is also given to new forms of abuse such as those who facilitate child trafficking; exploit chlldren sexually or use children in organised criminal activity (cannabis farms or street theft): Again, it will be seen that the particular circumstances of the Dawit case, should they arise again in a new case, would not sit easlly within the Usual remit of the CAIT. Whilst this definitional remit 'gap' still exists, therefore, and Is not directly within the power of the MPS to alter, we have acknowledged this, and have since 2008 developed safeguards to deal with it, Firstly, as we have seen, the additional layers of quality assurance provided to the CRIS by the Crime Assurance Unlt; to the Merlin by the Multi Agency Safeguarding Hubs provide two additional routes 20/11/2014

The family step an and

toward identifying the exceptional risk factors posed by the respective ages and relationship of the participants here, and the seriousness of the initially overlooked offence: Secondly; we have now instituted a 'backstop' procedure to be implemented in the event of a future Dawit-style uncerlainty_ arising regarding which unit would deal. The 'Frequently Asked Questions' section of the internal MPS Intranet Community Safety Unit website expresses it in the following terms: "Q: Does the CSU have to investigate Domestic Abuse incidents where one or more of the parties is under 16 years old?" "A: Though this will not be flagged as a DA incident as per MPS & ACPO policy the chances are that all the elements are there for a DA case; The likelihood is that the perpetrator will continue to commit further offences against this and other victims: If the case does not fali within the remlt of the SCD(5) CAIT {hen generally the advice is for the CSU to investigate due to the unique nature of DA, thus preventing further repeat victimisation and increased seriousness of incidents. [my emphasis] Responsibility for adjudicating in any dispute falls ultimately to the Crime Manager (Detective Chief Inspector) responsible for the Borough which 'owns' the crime, under Nalional Crime Reporling Guldelines In conclusion on this point, therefore , am confident that our layered quality assurance procedures and 'backstop' process are now sufficient to capture and resolve any 'remit' difficulties which might arise from current national crime definitions; 5: Use of Interpreters You wrote: "There appeared lo be some reluctance to use the interpreting service, s0 that the mother was never interviewed: Response Since 2008, routes to access immediate translation services for initial communication with victims and witnesses, together with arrangements to access securily-checked and court-qualified interpreters for more considered encounters such as victim witness statement taking, suspect interviewing; Or court appearances have been streamlined improved:. The MPS is consciously recruiting from a wider pool of diverse language speakers, and acknowledging the spontaneous availability of the many bilingual officers and staff we already employ: Work is in hand to use a database of these skills to improve our ability to engage with a diverse public; Meanwhile; dual handset telephones in the majority of police station front offices and custody suites enable front office staff to quickly set up three way instantaneous translation with members of the public who are native speakers in any language, using a commercial interpretation service, 'Language Line', available 24/7 It can also be used by sharing a single telephone if necessary, so, if required, officers and staff can communicate with people via interpreter at their home addresses, on the street, or elsewhere, usually within minutes of placing a request with the service. This service is usually sufficient to oblain details for an initial crime report, and to make arrangements for more thoroughgoing interpretation If required. As discussed above, initiai training and supporling 'Toolkits' both highlight this service to officers and staff, CCTV is also increasingly being used to provide rapid 'telepresence' translation to some stations for lengthier pre-planned encounters, where a centrally based interpreter can be booked to 'attend' stations remotely without having to incur extended travelling times. Finally, a centralised booking system managed by the Interpreter Deployment Team means that ofiicers no longer have to contact a series of possible interpreters themselves, but can call a single central number any time of the or night to book an attendance In person. In shorl, any future failure to request suitable interpretation for a member of the public at any from initial encounter to court appearance will Iikely now be an issue for the individual officer concerned to justify; not for the organisation; which has taken significant steps since 2008 to provide a comprehensive and easily accessed range of translation services for use by all of our staff. 20/11/2014

and and day point and

Conclusion The Metropolitan Police Service endeavours always to be a learning organisation. Whilst human errors may on occasion prevent us from delivering the quality of service we aspire to, hope you will agree with me that since 2008 we have made significant improvements in" our business processes. The developments highlighted here, in the areas of training and reference materials for staff, investigator accreditation quality assurance, supervision, and provision of support resources, will, am sure, g0 a long way toward mitigating the risk of future such incidents, of the kind the tragic case of Arsema Dawit highlighted, occurring again If you have questions in relation to this letter, please do not hesitate to contact me. Iowv ducenl Commander Security 20/11/2014

any

Report sections

Investigation and inquest
I opened an Article 2 inquest following a High Court Order in November 2012 into the death of Arsema Dawit, aged 15,on 02.06.08_ She was stabbed by a former friend who had been stalking her; The conclusion of the inquest delivered by the jury on Friday 26th October 2014 was unlawful killing, (dying from multiple injuries).
Circumstances of the death
The jury described the circumstances of the death, an extract of which follows death follows the report the family made to the police on 30.04.08 in which they reported several incidents relating to the deceased. This report was recorded on the CRIS system, the limitations of the CRIS report enabled several assumptions to be made. The principal offence was recorded as ABH and the investigation followed this line of inquiry: Had the principal offence been recorded and verified as a threat to kill, a risk assessment would have been carried out, which would have recognised and prioritised the threat to kill as urgent: The subsequent police investigation was inadequate for a threat to kill. The police investigation was insufficient and not carried out in & timely manner. There were insufficient measures taken in trying to communicate with the family as interpretation was required and the family home was not visited_ There is no evidence of the family contacting the police during the month of May after the initial report, was minimal supervision of this case and the case was hampered by the denials of the deceased that a report had ever been made
Action should be taken
In my opinion action should be taken to prevent future deaths and believe the MPS have the power to take such action andlor report on such action as has been taken with respect to these five concerns_

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Report details

Reference
2014-0442
Date of report
13 October 2014
Coroner
Andrew Harris
Coroner area
London (Inner South)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Dec 2014 (estimated).

Sent to

Metropolitan Police Service

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