Source · IOPC Learning Case

Investigation into the West Yorkshire Police response to reports of injuries to a one-year-old child – West Yorkshire Police, June 2020

West Yorkshire Police Ref: 2020/143305 Recommended 18 Aug 2023 Response due 13 Oct 2023

Death and serious injury

Case background

Text published by the IOPC.

On 21 June 2020, the father of a one-year-old child, made a call for concern to West Yorkshire Police (WYP), after he had received photographs of bruising to his daughter’s face. At this time, the child was living with her mother and her mother’s female partner. WYP responded and examined the child. Following discussions with the WYP Safeguarding Unit and Children’s Social Care (CSC), it was decided that the child would be taken to a local hospital for a medical examination by a doctor, to ascertain the cause of the injuries. Following that examination, the doctor was of the opinion that the injuries were caused accidentally. The child was then released back into the custody of her mother.

On 31 August 2020, the child’s father made a further call for concern to WYP, after receiving a video showing bruising to his daughter’s face. WYP made attempts to locate the child and her mother after being directed to an address the father had provide to the police which proved to be incorrect, officers then made attempts to contact the mother by telephone. On speaking to her, the mother explained that they were on a family holiday in Scotland and would be returning the following day for a pre-arranged meeting with CSC as CSC had also been made aware of the alleged bruising to the child’s face.

After receiving that information, WYP did not attempt to locate the child and examine her themselves and allowed CSC to continue with their meeting with the family and examination of the child. Following that meeting, CSC informed WYP that the injuries were thought to be accidental and that the complaints being made by family members were malicious, as the child’s mother and partner were in a same sex relationship.

On 22 September 2020, the Yorkshire Ambulance Service responded to a call from the child’s home. They found the child unresponsive and took her to a local hospital, where very sadly, despite attempts to revive her, she was later pronounced dead.

In October 2020, we commenced an independent investigation into the WYP response to the calls from the child’s father, however, this was pended until the completion of the criminal trial of her mother and partner in December 2021. The mother’s partner was found guilty of murder and sentenced to life imprisonment, with a recommendation that she should serve at least 25 years in custody while the child’s mother was found guilty of allowing or causing the death of a child and was given a custodial sentence of eight years, later increased to 12 years.

During our investigation, we gathered a large volume of evidence, including, telephone call recordings, police radio transmissions, body worn video recordings, witness statements and other associated documents from the WYP criminal investigation, police incident logs and other associated police documents as well as local and national police policy and procedures. We also obtained a large volume of statements from police and police civilian staff. We also liaised with and obtained the report completed by the National Children’s Safeguarding Review Panel. The investigation concluded there was no indication any police officer may have behaved in a manner that would justify the bringing of disciplinary proceedings or committed a criminal offence.

We concluded our investigation in November 2022 and shared our report with WYP who agreed with our findings. On 13 February 2023, HM Coroner decided there was no requirement to hold an inquest into the child’s death.

We carefully considered whether there were any 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. Our investigation highlighted a number of areas of learning for WYP resulting in learning recommendations.

Recommendations and responses

7 indexed

Recommendation 1

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommends that West Yorkshire Police ensures that it is able to adequately resource the supervisory responsibilities in the safeguarding unit, taking into account both the number of people required and their levels of training and experience.

This follows an IOPC investigation in relation to the actions of the police in response to safeguarding concerns for a child. An officer carrying out supervisory responsibilities in the Safeguarding Unit had recently joined the unit and had not yet been on a safeguarding supervisors’ course but was relying on previous experience in other safeguarding roles. In addition to this, he was working alone where normally the expectation would be to have two supervisors working together, one acting as duty Detective Sergeant and the other carrying out clerical duties. These factors taken together may have contributed to missed opportunities to put safeguarding in place.

Response published by the IOPC

Accepted

West Yorkshire Police is in the final stages of the implementation of its forcewide Safeguarding Review which aimed, in part, to meet the Cause for Concern set out in the 2018/19 PEEL report from the HMIC.

“The capacity and capability for West Yorkshire Police to effectively deal with investigations involving vulnerability is a cause of concern”.

The initial review aimed to increase staffing, improve officer to supervisor ratios and to better equip officers for their role with dedicated and accredited training.

All objectives from this review have now been completed and the Cause for Concern signed off by the HMIC. This staffing achievement for Safeguarding puts West Yorkshire Police ahead of other Forces and also allows for the force to have dedicated Child Protection teams in each of its five districts rather than generalised Safeguarding teams to allow specialist focus in this area and for dedicated CP officers and supervisors to remain in post.

The challenge remains however in terms of sustainability of these staffing numbers with limited availability of PIP2 qualified Detectives posing a national problem and the increases in demand in areas such as Domestic Abuse, RASSO and CSEA, Abuse and Neglect.

In February 2023, as part of the post implementation review, the Chief Officer’s Team agreed to the following further recommendations.

1. Growth Bid for Safeguarding comprising of 67 Police Officers, 4 D/Inspectors and 5 D/Sergeants, from the remaining unallocated PUP budget. 2. Safeguarding Investigation teams to move to a 4-week shift pattern. To accommodate a 4-week shift pattern there will be a requirement for a further uplift (additional to the above) of 8 D/Inspectors and 15 D/Sergeants.

This was designed to have a further beneficial impact on Safeguarding investigations, with the aim of greater supervisory oversight, increased supervisor to investigator ratios, protected workload days, increased positive outcomes, victim satisfaction, reduction in the longevity of investigations and increased staff wellbeing and investigative experience and confidence. In terms of training, West Yorkshire Police are currently conducting a detailed training needs analysis survey and are working with Learning and Organisational Development to ensure the current and future training needs for Child Protection officers and staff are prioritised and planned into the force training plan for 2024/25.

The force tracks all accreditation through its Chronicle Accreditation Board including (but not exhaustively) SCAIDP, Tier 2 and Safeguarding Supervisor’s Courses).

Several training methods are being utilised in addition to College of Policing mandated courses. The force has recently run a bitesize input for all Child Protection officers and staff on neglect in conjunction with the CPS. In addition, the Safeguarding Central Governance Unit has planned training sessions (starting in September 2023) for all frontline response officers on how to respond to Child Protection matters (including voice of the child and accurate recording and documenting of child protection concerns) and this will also be reinforced as the force undertakes the SHAREDD training programme as a pilot force in conjunction with the NSPCC into early 2024.

Direct entry detective recruitment is ongoing and this provides a pathway for officers to enter the safeguarding investigation roles however the challenge remains around sufficient numbers of mentors in safeguarding teams to deliver the agreed safeguarding uplift of 67 Police Constables, five Sergeants and four Detective Inspectors.

The proposed review of the shift pattern has proposals that would enable four protected investigation and CPD days every four weeks, increase the number of days working alongside statutory partners and give better access to victims during daytime hours. A new Chief Inspector to oversee this implementation is anticipated in the next few months and this will then allow for consultation with officers, staff and the unions with the aim to introduce the new working pattern in early 2024.

The full implementation of all these proposals should allow for the force to meet this recommendation by ensuring that Child Protection Teams are specifically recruited, trained and adequately supervised to carry out their roles and responsibilities. These issues will continue to be an area of priority for the force and will be monitored via the PVP Strategic Board as they are now.

Check the original case on the IOPC website

Recommendation 2

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommend that West Yorkshire Police (WYP) take steps to ensure that all officers and staff complete a NICHE (Occurrence Entry Log) with all relevant information OEL following a potential complaint of a crime and to ensure that all OEL investigative tasks and communications are documented on the OEL.

This follows an IOPC investigation whereby WYP staff failed to complete a NICHE OEL, following a concern for welfare telephone call and complaint of an assault of a young child. The WYP NICHE OEL system is used by WYP as its core operational system, supporting the management of information in relation to people, locations, vehicles and incidents, and compliant with the principal doctrines of UK policing. The system supports crime, intelligence, incidents, property, custody and case file preparation.

Response published by the IOPC

Accepted:

West Yorkshire Police has a force Investigations Policy which sets out expectations in this area. Within this policy are the force requirements for initial response, allocation, review and finalisation. This policy was re-written in February 2023 to ensure that it is clear as to which templates and which information should be included on a Niche occurrence. This includes the expectation that all relevant information regarding an incident with an associated Niche is recorded on the OEL.

The Safeguarding Children and Young People policy reinforces this and also supports decision making for front line responders, supervisors and specialist investigating officers within the context of Working Together and The Children’s Act 1989.

Therefore, this is an issue of compliance. Since mid-November 2021, a Vulnerable Victims Audit has been conducted quarterly by the Force Crime Registrar with the support of the Safeguarding Central Governance Unit to assess and improve practice in the accurate recording of information received into force as relates to children both from the 999/101 system and from other agencies. This includes assessment of how accurately the information is recorded on the OEL. This work will continue as a standing item on the CDI Strategic Steering Group which is chaired by the DCC. We have improved compliance in this area and will continue to apply focus in this area through audit work.

In terms of training, all new staff and student officers are given a direct input on the correct use of niche and of the correct recording of information. This is also reiterated in Safeguarding Supervisor courses and inputs to newly promoted Sergeants and Inspectors as part of their training.

Call handlers receive an input on understanding and responding to vulnerability in their initial training and this is also monitored through the audit work in the CDI SSG.

The Safeguarding Central Governance Unit has planned training sessions (starting in September 2023) for all frontline response officers on how to respond to Child Protection matters (including voice of the child and accurate recording and documenting of child protection concerns) and this will also be reinforced as the force undertakes the SHAREDD training programme as a pilot force in conjunction with the NSPCC into early 2024.

Check the original case on the IOPC website

Recommendation 3

Link to recommendation · Awaiting Response

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommend that West Yorkshire Police (WYP) ensure that when holding a strategy meeting with other agencies, all information given and received, including non-recent information, should be clearly documented and shared, to include the strategy discussions and rationale given for the agreed course of action using the police National Decision Making Model (NDM).

This follows an IOPC led investigation whereby West Yorkshire Police (WYP) and Children’s Social Care (CSC) failed to adequately record and share relevant historical and up to date information including decision making rationales which would have allowed for all of the known intelligence to be recorded and revealed appropriately. Although it is recognised that WYP form part of a holistic group of relevant partner agencies, each with their own responsibilities WYP should ensure that the WYP safeguarding children and young person’s policy, is adhered to and which states that ‘When a strategy discussion is held it should be documented on both the child protection occurrence (NICHE OEL) and the CSC Management occurrence.

Response

As stated in the recommendation, the Safeguarding Children and Young Person’s Policy gives clear expectations that Niche is used to document and record a Strategy Discussion under Section 47 and that minutes should be attached (when available).

The force is currently conducting a multi-agency and Chief Supt led MASH Review in response to the AFI from the 2021/22 HMICFRS PEEL Inspection which states;

“The force should ensure that when it is sharing information with children’s social care organisations about vulnerable children, a full picture of information is shared”

As part of the review, the force and partners have audited and assessed the current approach for effectiveness and ease of use. As a result, a new procedure has been developed that will be more user-friendly and provide consistency over five districts. Force policy will be changed to reflect this.

The new procedure will include a new category of Niche occurrence under ‘Child Protection – Information Sharing’ and added Supervisory oversight to every record of Strategy Discussions created.

Once this has been established, training will be provided to officers and staff working in the MASH/Front Door arrangements and Child Protection Departments as well as being included on the Safeguarding Supervisors Course.

To further in this practice, West Yorkshire Police has developed a Child Protection Power BI App that will allow for monitoring performance and compliance with strategy recording and information sharing across the districts.

Compliance will be monitored through inclusion on the audit timetable held at the Safeguarding Central Governance Unit.

Check the original case on the IOPC website

Recommendation 4

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommends that West Yorkshire Police takes steps to ensure that investigating officers ensure that where a potential line of enquiry is identified but determined not to be ‘reasonable’ in line with the Code, an appropriate rationale should be recorded.

This follows an IOPC investigation into police handling of a case where an allegation was made that a child had been assaulted by her mother with a shoe. This allegation was not followed up or investigated and no rationale was recorded for the lack of further action.

Response published by the IOPC

Accepted

Therefore, this is an issue of compliance, training and reinforcement. In terms of training, all new staff and student officers are given a direct input on the correct use of niche and of the correct recording of information. This is also reiterated in Safeguarding Supervisor courses and inputs to newly promoted Sergeants and Inspectors as part of their training.

Call handlers receive an input on understanding and responding to vulnerability in their initial training and this is also monitored through the audit work in the CDI SSG.

The Safeguarding Central Governance Unit has planned training sessions (starting in September 2023) for all frontline response officers on how to respond to Child Protection matters and this will also be reinforced as the force undertakes the SHAREDD training programme as a pilot force in conjunction with the NSPCC into early 2024.

Compliance will be monitored through inclusion on the audit timetable held at the Safeguarding Central Governance Unit and through ongoing work into Investigations Improvement held under the Criminal Justice strand led by the ACC Specialist Crime.

Check the original case on the IOPC website

Recommendation 5

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommends that West Yorkshire Police (WYP) remind all WYP control room staff of the importance of protecting vulnerable victims of domestic abuse by consistent and effective use of the THRIVE process, to include a review of their THRIVE training process to ensure that WYP control room staff understand how to conduct THRIVE risk assessments, document their THRIVE rationale and receive the appropriate training..

This follows an IOPC led investigation whereby a concern for welfare telephone call for a vulnerable young child was not resourced for a number of days. Although WYP were given incorrect information and they did attempt to resource to this incident at the points when resourcing was attempted the incident was not re-thrived or re-graded. The THRIVE model is used by many police forces in England and Wales. It was developed as a framework for risk assessing public need, vulnerability and other key elements of service delivery. THRIVE stands for Threat, Harm, Risk, Investigation, Vulnerability and Engagement.

Response published by the IOPC

Accepted

In October and November 2021 Contact THRIVE training was reformed and the new training was included in the Initial Contact training course which all new Contact staff undertake, including PC’s and internal staff transferring into the department as dispatchers, we do not take it as a given that existing colleagues understand the importance and intricacies of a full and proper risk assessment. As well as being included in the new course for new staff, all existing staff were given face to face training around THRIVE, the new format and what to take into consideration including every element of the mnemonic.

More recently (commencing December 2022) we have undertaken further work around THRIVE, including monthly audits of up to 300 logs with allegations which carry the greater risk. This allows us to understand our position in risk management of incident reports and refine our working practices, give feedback to individuals, and, if necessary, arrange training. Part of this process has also been to drive the importance of the re-THRIVE by dispatchers. The initial call handler makes a risk assessment, using the THRIVE principles based on the information given by the caller and their training around awareness of safeguarding/DA/mental health etc. It is not entirely caller led, and it does not take into account any information on police systems. The log is then passed through to dispatch where the expectation is that the dispatcher will quickly carry out background checks on local/national systems as appropriate. Any pertinent information identified should be recorded on the log, and the original THRIVE is then reconsidered in light of these checks. The result being either the dispatcher acknowledges that there has been no change to the THRIVE, or they write a comprehensive re-THRIVE in which the risk grading is increased/decreased based upon this information. The audits focus on the following areas (amongst other elements):

• THRIVE at initial contact/log creation • Consideration of vulnerability by initial call handler • Acknowledgement of whether this is a repeat call by the call taker • Whether system checks have taken place by dispatchers to establish any previous history or vulnerabilities not identified in the initial call • Re-THRIVE • Consideration of vulnerability by dispatcher • Acknowledgement of whether this is a repeat call by the dispatcher

These audits have demonstrated that at first point of contact, we record an accurate THRIVE in 97.1% of all calls. When carrying out re-THRIVEs this is done accurately on average 90.9% of the time. June and July seeing 95% and 94.8% accuracy respectively.

In summary, the WYP Senior Contact Manager is confident that we have administered suitable training, which has been taken on board, we continue to monitor progress and actively seek to improve and are checking accuracy regularly for a consistent response to all our victims, with emphasis on those most vulnerable, and the identification of such vulnerabilities and we continuously strive to ensure our risk assessments meet the needs of our callers and victims.

Check the original case on the IOPC website

Recommendation 6

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommend that West Yorkshire Police (WYP) ensure that following reports of injuries to vulnerable children they locate and examine the injured child themselves rather than rely on opinions from other agencies.

Following an IOPC led investigation it was identified that WYP received a report of a potential assault of a vulnerable child, who was not at her place of residence. WYP did not make attempts to locate, examine and assess the risk to the child themselves but relied on the opinion of the child's mother as to the child's location and Children’s Social Care CSC following the CSC performing their own visit to the family. This should allow for a multi-agency approach, whereby relevant agencies conduct their own independent investigations and then work together to share information and robustly challenge each other’s evidence on order to produce a holistic approach to safeguarding children in such circumstances.

Response published by the IOPC

Accepted

The Safeguarding Children and Young Person’s Policy gives clear expectations around when a Section 47 Strategy discussion should take place and how officers and staff should engage with and liaise with partner agencies over concerns reported about the welfare of children. This is under-pinned by Working Together 2018 and The Children’s Act 1989.

West Yorkshire Police accepts that it could have made further enquiries to establish the whereabouts of Miss Hobson and Star when it was stated that they were in Scotland. This particular case would have met the threshold for a Strategy discussion under S47 and had one taken place, a joint decision could have been made and appropriately recorded as to what action would be taken to locate and assess Star rather than waiting for a later meeting. This could have included utilising Police Scotland to assist.

As no discussion was held, West Yorkshire Police allowed CSC to take the lead in deciding that no further action was required on our part which does not meet the aims of Working Together around the sharing of information.

The force is currently conducting a multi-agency and Chief Supt led MASH Review in response to the AFI from the 2021/22 HMICFRS PEEL Inspection which states;

“The force should ensure that when it is sharing information with children’s social care organisations about vulnerable children, a full picture of information is shared”

As part of the ongoing review, the force aims to ensure that decisions made in relation to children are multi-agency and should not be taken unilaterally by a single agency. Nor should any investigation be taken independently or in isolation.

Process mapping has been undertaken at all five locations. Best practice has been identified around the recording of a variety of processes such as strategy meetings, police intelligence checks and 3rd party referrals. and work is underway to bring this together before implementation across Districts.

To assist with this, West Yorkshire Police has developed a Child Protection Power BI App that will allow for monitoring performance and compliance with strategy recording and information sharing across the districts.

The Safeguarding Central Governance Unit has planned training sessions (starting in September 2023) for all frontline response officers on how to respond to Child Protection matters and this will also be reinforced as the force undertakes the SHAREDD training programme as a pilot force in conjunction with the NSPCC into early 2024.

Compliance and practice in relation to reports of Child Protection matters will be monitored through inclusion on the audit timetable held at the Safeguarding Central Governance Unit.

Check the original case on the IOPC website

Recommendation 7

Link to recommendation · Accepted

Addressed to: West Yorkshire Police

Linked bodies: West Yorkshire Police

IOPC recommendation

The IOPC recommend that West Yorkshire Police (WYP) ensure that they review their mechanisms already in place, by the use of dip sampling or regular audits between WYP, Children’s Social Care (CSC) and their partner agencies to ensure that WYP fulfil its obligations to collaborate with all relevant stakeholders share all relevant information and work together to provide a clear and strategic oversight of all complaints regarding vulnerable children.

This follows an IOPC led investigation whereby missed opportunities were identified with the recording and sharing of information and strategic holistic decision making between partner agencies resulted in single agency decision making instead of a multi-agency strategic approach. This investigation and the HMICFRS PEEL report at paragraph has identified that there are MASHs in place but there’s a lack of clarity around working practices.

Response published by the IOPC

Accepted

In 2021, West Yorkshire Police sought to develop its approach to Child Abuse through a dedicated CSEA, Abuse and Neglect Tactical Plan. The progress against this plan is scrutinised through a force Tactical Delivery Group and the Protecting Vulnerable People Strategic Board. The ongoing improvement and development of Partnership working under Working Together 2018 is a key aspect of this plan.

In 2022 the force completed its roll out of the PPN referral mechanism allowing for one single process by which officers can refer into the Front Door/MASH replacing a previously less uniform and auditable system.

The force is currently conducting a multi-agency and Chief Supt led MASH Review in response to the AFI from the 2021/22 HMICFRS PEEL Inspection which states;

“The force should ensure that when it is sharing information with children’s social care organisations about vulnerable children, a full picture of information is shared”

The review is multi-agency and based upon a joint Terms of Reference.

Work is progressing to improve the clarity of working practices across the five District MASH teams with partners. Process mapping has been undertaken at all five locations, with discrepancies discovered around the recording of a variety of processes such as strategy meetings, police intelligence checks and 3rd party referrals. Best practice has been identified and work is underway to bring this together, before implementation across Districts.

Compliance will be monitored through inclusion on the audit timetable held at the Safeguarding Central Governance Unit and this will include ongoing joint audit which has proven key in the review process to date.

Check the original case on the IOPC website