Source · IOPC Learning Case

Complaints raised by family after recovery of young teenager's body - South Wales Police, 2019

South Wales Police Ref: 2019/122226 Recommended 22 Jun 2021 Response due 17 Aug 2021

Welfare and vulnerable people

Case background

Text published by the IOPC.

Following a series of complaints made by the mother of a son who drowned in the River Cynon in July 2019, we carried out a thorough investigation into the actions South Wales Police took after the recovery of his body.

Our investigation found some shortcomings in the way the force dealt with the family and in particular, that officers’ communication with them could have been better. However, we found no grounds for any disciplinary proceedings to be brought against any of the officers involved.

The complaints included that South Wales Police had concluded wrongly, and within 24 hours, that his death was a ‘tragic accident’. His family questioned whether a proper and thorough investigation had been conducted by police and felt they had been treated insensitively because of their ethnicity. They also complained that officers had not answered reasonable questions they had asked.

Our investigation, which began in July 2019, did not uphold the complaint that officers concluded that he died as a result of an accident without a proper investigation. The evidence indicates that comments made at an initial meeting between his relatives and officers may have created this impression, which was regrettable. Witness accounts and police logs demonstrated how officers continued to explore hypotheses, undertake enquiries and investigate the incident for a number of weeks and as such, we did not consider that the investigation was prematurely concluded.

Taking into account the family’s perception that the investigation into his death had ended prematurely, together with some difficult early exchanges with police officers, it is understandable they held suspicions of racial bias. However, the death investigation was in fact continuing and the evidence gathered in the course of our enquiries does not suggest that the family were treated less favourably by the police because of their race.

We found that communication between the force and the family could have been better. The officers who attended an initial meeting with the family on 2 July were not well-briefed or best placed to answer their questions. A clear communication strategy at that first visit would have been highly desirable, given the traumatic nature of the incident, the large number of people involved, and the level of community interest.

We upheld one complaint, which centred around another meeting between the family and South Wales Police. This descended into a disagreement, when his family voiced repeated concerns about possible racism by the force. We considered that a police officer’s approach at that meeting was ill-judged and insensitive, particularly taking into account the upset and distress the family were experiencing. While we found no disciplinary case to answer, we recommended management action for the officer involved, with additional training on dealing with bereaved families, equality and diversity, and unconscious bias.

In examining each individual complaint, we considered whether South Wales Police followed relevant policies and procedures. We obtained accounts from fifteen officers involved, and their conduct, the progress of the investigation, and police interaction with the family were comprehensively reviewed.

Issuing our findings from the investigation has awaited the end of an inquest. The coroner recorded a narrative conclusion in January 2024.

We issued three organisational learning recommendations to address areas for systemic improvement.

Recommendations and responses

3 indexed

Recommendation 1

Link to recommendation · Accepted

Addressed to: South Wales Police

Linked bodies: South Wales Police

IOPC recommendation

The IOPC recommends that South Wales Police reviews its Sudden and Unexpected Deaths Procedure, Unexpected Child Death FIM Guide, and Form F13 Report of Sudden Death (notes of guidance) to ensure they are consistent with one another in respect of the requirements for notification to be made to an SIO and the attendance of a CID supervisor at the scene. Also, that they are consistent with national guidance, in particular the Public Health Wales Procedural Response to Unexpected Deaths in Childhood (PRUDiC), and are otherwise fit for purpose.

This follows an IOPC investigation into the death of a child where it was found that an SIO was not notified on the day of the incident and a CID supervisor did not attend the scene promptly.

Response published by the IOPC

Accepted:

South Wales Police’s sudden and unexpected death procedure (in particular child death) has been reviewed and amendments made in relation to SIO contact and the on duty CID supervisor attending the scene.

Unexpected Child Death FIM guide, has been reviewed and the updated policy will reflect the wording of the FIM guidance.

Form ‘F.13’ is now fully electronic along with a guidance document attached to it. This new electronic version of the ‘F.13’ and the amended guidance can be provided as supporting material.

All the above actions have been reviewed and following recommendations will be consistent with one another.

The Public Health Wales PRUDiC (2018) guidance covers safeguarding and learning post the death of a child, however there are sections of it that cover the initial police response.

These sections ( (Role of Police) (Supporting bereaved families) Appendix 1 Lullaby Trust advice re Talking with Bereaved Parents), have been reviewed by DI Stuart Wales (SIO and force lead on operational response to child death)

In summary all the above points will be consistent with PRUDiC guidance following the recommendations.

A one page infographic which was circulated across the workforce at the time of implementation to highlight the changes in the 2018 PRUDiC refresh

Check the original case on the IOPC website

Recommendation 2

Link to recommendation · Accepted

Addressed to: South Wales Police

Linked bodies: South Wales Police

IOPC recommendation

The IOPC recommends that South Wales Police takes steps to ensure all relevant officers and staff, included but not limited to: Gold, Silver, and Bronze Commanders and Force Incident Managers, receive training on the following policies and how they interact with one another: Public Health Wales Response to Unexpected Deaths in childhood (PRUDiC); South Wales Police Sudden and Unexpected Deaths Procedure; South Wales Police Unexpected Child Death FIM Guide; and South Wales Police Form F13 Report of Sudden Death (notes of guidance).

This follows an IOPC investigation into the death of a child where it was found that an SIO was not notified on the day of the incident and a CID supervisor did not attend the scene promptly.

Response published by the IOPC

Accepted:

Those who conduct the roles of Gold, Silver, Bronze and FIM should be briefed via an awareness raising exercise, this should take the form of a power point presentation completed by DI [redacted] who is the force lead for child death and is an experienced PIP3 accredited Senior Investigating Officer (SIO).

This exercise should also include BCU SIO’s and detective sergeants. This message should also be re-affirmed during the ‘Back to Basics’ training input already provided by DI [redacted] at PIP2 courses for detective constables and sergeants.

A further ‘Back to Basics’ input is also provided during courses for student officers, this will ensure the wider workforce are captured.

Check the original case on the IOPC website

Recommendation 3

Link to recommendation · Accepted

Addressed to: South Wales Police

Linked bodies: South Wales Police

IOPC recommendation

The IOPC recommends that South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers/staff when dealing with bereaved families.

There should be clear agreement in advance about what information can be shared with a family, and a record made of the information provided. In addition, any questions asked by the family should be recorded and a record made of answers provided to them. This recorded information should be clearly communicated and/or accessible to relevant officers and staff.

This follows an IOPC investigation into the death of a child where it was found there was inadequate briefing of officers who dealt with the family, who were expected to self-brief from the incident log. Furthermore, no formal record was made of what information was provided to the family or of what questions the family had raised.

Response published by the IOPC

Accepted:

South Wales Police has invested heavily in creating capability and capacity in respect of its FLO cadre. Significant training and on-going CPD of FLO’s, Family liaison Co-ordinators (FLC’s) and Family Liaison Advisors (FLA’s) continues to be a focus for the force.

The forces FLO training is nationally approved and follows the syllabus set by the College of Policing.

FLO courses are College of Policing approved and are delivered ‘in house’ by the forces investigative training unit. SWP investigative training unit are an external training provider to other forces.

Force FLO lead DCI and co-ordinator DS sit on the National Family Liaison Executive Board (this is NPCC led). DCI also leads a national piece of work on how sharing of learning and best practice from reviews can take place nationally.

In force there is annual CPD for all FLO’s, South Wales Police also lead on a regional collaborative approach to its FLO’s CPD. FLC’s and FLO’s within force also attend national CPD events – learning from deployments and national best practices is cascaded to the wider workforce via a newsletter which is circulated on a quarterly basis.

DI who is the force lead on sudden death, provides regular inputs at student officer training courses and PIP2 detective training courses. During the input he presents a ‘Back to Basics’ presentation in relation to sudden death attendance and investigation; this presentation should include an enhanced briefing upon the importance of effective communications with bereaved families.

The quarterly force newsletter which is well established should include an awareness raising article for the wider workforce on the importance of effective communication with bereaved families.

Electronic form F.13 and bereaved family guidance to be updated to include the amendments to policy regarding SIO contact and the on duty CID supervisor to attend the scene.

Inputs on child death are provided by investigative training and an experienced PIP3 accredited SIO at PIP2 courses, these are aimed at detective constables through to SIO’s.

Child death also forms part of the PIP2 manager and SIO pathway training.

Training is provided across the detective cohort from trainee detective through to those on the SIO pathway.

The subject matter is also provided during the ‘back to basics’ input with student officers, during their initial training phase.

The final proposed action for the force is to raise awareness amongst the wider workforce beyond the detective and student officer cohort. This will ensure South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers and staff when dealing with bereaved families. This should be co-ordinated by the forces family liaison lead DCI and child death lead DI who will prepare a communications piece around family bereavement and messaging in line with the PRUDiC principles and liaise with LDS to ensure a co-ordinated approach to training.

Check the original case on the IOPC website