Commissioner’s Report
Independent Investigation
into police contact
with Joanna Michael
prior to her death
Introduction
On 5 August 2009, Joanna Michael was brutally murdered in her own home by
Cyron Williams. On 11 March 2010 Williams pleaded guilty to Joanna’s murder and
the court sentenced him to life imprisonment with a minimum tariff of 20 years in
prison.
Both Gwent Police and South Wales Police handled Joanna’s emergency calls that
night and I decided that the IPCC would use its own investigators to independently
investigate both police forces’ responses to Joanna’s 999 calls. Joanna rang the
police because she needed urgent assistance and was denied timely help because
of a fatal combination of technological and human errors.
There was a public outcry at the time of Joanna’s murder, not least because she
called the police and there was a delay in their response. Some of the public debate
focussed on the closure of St Mellon’s police station outside of 9am-5pm normal
working hours and there was speculation that had the station been open then the
police may have got to Joanna in time to save her.
This speculation was inaccurate, not least because the police station at Rumney was
open and was a few minutes drive away from Joanna’s home. The IPCC
investigation has focussed on how the two police forces handled Joanna’s
emergency calls and the speed of their response.
The investigation also looked at how Joanna’s emergency phone calls from her
mobile phone were misrouted by the mobile phone mast system to Gwent Police
rather than South Wales Police, which was the police force for the St Mellons area
where she lived.
A young mother of two children lost her life after calling the police for assistance.
This was a terrible tragedy for Joanna’s children who lost their mother in the most
horrific circumstances. Her family have had to endure their own grief for their loss
and also have the responsibility to raise Joanna’s children.
I have ensured that Joanna’s family have been kept up-to-date with the progress of
the investigation and I am aware that this is the final part in this tragic case being
played out in the public domain. I am very grateful to Joanna’s family for the patience
they have shown in the final stages of the IPCC investigation as they have waited to
see our full investigation report.
Although the investigation itself concluded some time ago I wanted to ensure that
when the IPCC shared the outcomes with the family that we were also in a position
to set out what the two police forces intend to do about the individual discipline and
the many learning recommendations we have made in relation to police procedures
and policy.
There is a vital public interest in sharing the outcomes of our investigation, not least
in view of the concerns raised by the public and media. Because of the public
scrutiny of all the various matters relating to Joanna’s murder over the past 12
months that her family has had to endure I have decided that it will be more
appropriate in this case to publish a Commissioner’s Report.
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This enables me to present the key findings and recommendations from the
investigation and set out my own views, while sparing Joanna’s family from having
an unnecessary amount of personal information being put into the public domain.
Also, this was the second in a series of four murders from each of the four Welsh
forces that were referred to the IPCC during July and August 2009. In a population
the size of Wales, four murders within a month is not an unusually large number.
However, for the police forces to refer to the IPCC how they dealt with calls for
concern in each case is highly unusual. There were some common factors between
each of these cases and I have ensured that the separate investigations have
covered these core issues around call handling and domestic abuse in a coordinated
way.
I have done this in order that I can ensure that proper action is taken to take the
various issues forward in a coordinated way. This will ensure proper learning and
that action can be taken to minimise some of these tragic events from occurring
again.
Investigation Terms of Reference
1.
The terms of reference are set as:
To fully investigate the circumstances surrounding Gwent Police and South
Wales Police interaction with Joanna Louise Michael, prior to the death of Ms
Michael on 5 August 2009.
The investigation to include:
A full assessment of all documented and purported contacts between Ms
Michael, and any other individuals, and the police, in relation to the ‘999’
emergency calls received by Gwent Police and subsequently relayed to South
Wales Police regarding incidents at Joanna’s home in St Mellons on 5 August
2009.
The investigation will consider the actual responses to those contacts and the
appropriate responses to those contacts.
It will consider whether there were any circumstances in relation to the
contacts, actions or inaction by Gwent Police and South Wales Police which
could have impacted on or potentially prevented the death of Joanna Louise
Michael. This will be done in the context of potential public concern for the
prevention of such tragic events through timely intervention.
Previous police contact with Joanna Michael will be analysed with particular
consideration to any intelligence and/or risk assessment relating to domestic
abuse.
The investigation will include an analysis of any recent domestic abuse related
homicide reviews conducted by Gwent Police and South Wales Police and
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consider any learning and recommendations that may have been made as a
consequence of the review process.
The matter of the telecommunications process relating to ‘999’ emergency
calls will be considered and analysed in respect of the cross border
arrangements between Gwent Police and South Wales Police relating to
misdirected calls.
The purpose of the Investigation will be to consider and report whether:
A criminal offence has been committed by any officer or member of police
staff whose conduct is investigated.
Disciplinary proceedings should be brought against any officer or member of
police staff whose conduct is investigated.
Any investigated complaint is supported by the evidence.
There is any learning for the police service (see paragraph 5)
Case Summary
At 2.29am on 5 August 2009 Joanna dialled 999 and made her first emergency call
to the police. This call was received by Gwent Police because her call was picked up
by a telephone mast inside the Gwent Police area. The call operator established that
Joanna had been assaulted and was informed by Joanna that her ex-boyfriend had
taken her car and was going to return at any minute and assault her.
The operator did not ask Joanna the name of the suspect or description of the
offender and failed to establish if there were any children at the address - contrary to
force policy. The operator did ask for the details and registration of the vehicle that
Williams’ had taken. Further details about force policy and the learning identified can
be found in the Annex to this report.
The control room operator realising that Joanna was based in the South Wales
Police area, informed Joanna that Gwent Police would contact South Wales Police
and that she should keep her phone free as South Wales Police would probably call
her back.
The Gwent Police control room operator called South Wales Police and informed the
operator of Joanna’s details, that she had been assaulted and that the suspect was
going to come back and assault her again. However, she failed to tell SWP that
Joanna had told her that Williams would be back at any minute. The Gwent control
room operator did not give the details of the car that the suspect had taken and was
unable to provide any details about Williams.
On receiving the call from Gwent Police the South Wales Police control room
operator recorded Joanna’s name incorrectly as Gerard Michael and downgraded
the call from an ‘immediate’ response (which is the default grading for all calls and
requires police to respond as soon as possible) to a ‘priority’ response which
requires police to attend within 60 minutes. The SWP operator was unable to fully
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risk assess the decision to grade the call as requiring a priority response because he
had insufficient information to do so.
The SWP control operator allocated the call to two officers and wrongly assumed
that they would attend the incident straightaway because the officers were available
at the Rumney police station. Because the call was wrongly graded as requiring a
response within an hour the two police officers sensibly decided to check the police
computer for further intelligence about the address they were given. They made this
decision because of the lack of information they had been given when the call was
allocated to them.
At 2.43am Joanna made a further 999 call, which was again received by Gwent
Police, and in which Joanna is screaming and told the control room operator that she
was in St Mellons and then the phone line went dead. Gwent Police informed South
Wales Police of this development.
At 2.45am Gwent Police told SWP about this latest call and the SWP control room
operator then decided at 2.46am to re-grade the response to an incident requiring an
‘immediate’ response. The two officers were immediately despatched to St Mellons.
At 2.46am a member of the public called 999 and their call was misrouted to Gwent
Police as well and informed the operator that there was a domestic dispute at
Joanna’s house and said they could also hear children screaming.
At 2.49am a member of the public called the police (their call was also misrouted to
Gwent Police) and told them that somebody had been stabbed at Joanna’s address.
Gwent Police called for an ambulance and told SWP about this latest call and that an
ambulance had been called.
Officers arrived at approximately 2.50am, some five minutes after the call was
graded an immediate response to find that Joanna had been murdered.
Key investigation outcomes
Misrouted 999 calls The investigation looked into the issue of 999 calls from the
SWP area being misrouted through to Gwent Police and found that this was probably
because the nearest phone mast was located in the Gwent Police area. IPCC
investigators spoke to phone providers about this and to the police service. The
views expressed to the IPCC were that instances where this had happened were
rare, although record-keeping by phone companies providing the 999 service and
the police service itself was not systematic.
It should be noted that although the IPCC was told that mobile phone calls to the 999
service being misrouted was a rare occurrence, in this one incident both of Joanna’s
phone calls were misrouted to Gwent Police as were the two witnesses who had also
dialled 999. The learning report attached as an annex provides more detail about
this.
There is no easy solution to this issue, although some police forces have an
electronic transfer system where incidents are electronically transferred between
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forces. This has now been put in place between SWP and Gwent. The IPCC has
also addressed this issue in its learning bulletin it issues to the police service in
England and Wales. I will also be ensuring that the Association of Chief Police
Officers (ACPO) lead on call handling is sent our recommendation about the need
for a consistent, national approach to misrouted emergency calls.
Call handling The Gwent Police call handler was in breach of Gwent Policy policies
in failing to take proper details from Joanna and missed getting key information such
as: the injuries she had suffered; the offender’s name and description; how it was not
known how Williams had earlier entered the property; and whether there were any
children in the household. The call handler also failed to pass on key information to
SWP, such as the description and registration of the car Williams was using; that
Joanna had said he would be back any minute; details of the assault; or that she had
told Joanna to keep her phone free because SWP would call her back.
In fact, the tape of the call reveals that at times it seemed that the call handler was
not paying proper attention to Joanna, repeatedly asking her the same questions. At
one point the Gwent Police call handler talks to a third party and has to reassure
Joanna that she is listening to her.
When Gwent Police passed the call to South Wales Police, the police response was
down-graded from requiring an immediate response to needing a priority response.
The SWP call handler made this decision based on the insufficient information that
had been given to him by the Gwent call handler.
The obvious course of action in the circumstances of not being provided sufficient
information to carry out a proper risk assessment is to err on the side of caution and
deploy officers immediately. The victim can then be telephoned to reassure them
that officers have been dispatched and to obtain further information. If that then
required the call grading to be changed at least the decision would be based on the
full facts.
The investigation found that South Wales Police had three differing documents
available to staff to guide them about call grading criterion. This is confusing and the
force has agreed to review and rationalise their process into one coherent guide to
grade emergency call responses. This is further detailed in the learning report
attached.
Domestic abuse training The IPCC investigation identified that the Gwent Police
call handler, despite being employed by the force for 12 years, had never attended
any force training courses on domestic abuse. This is despite the fact that domestic
abuse cases are a high proportion of all calls received by police call handling teams
and require specific knowledge in the way that they are handled. The investigation
also found that both forces did not keep proper records of the domestic abuse
training attended by individual staff. And therefore it appears that vital training can be
attended or missed at will by an individual without appropriate management followup.
However, despite the lack of domestic abuse awareness training provided by Gwent
Police to the call handler the investigation found that this did not excuse the basic
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lack of competence in obtaining simple information and passing on the crucial
elements of it to South Wales Police.
The investigation found that the SWP call handler failed to obtain sufficient
information to carry-out a full risk assessment of Joanna’s call and therefore he failed
to correctly grade the call.
Domestic abuse history The IPCC investigation also identified that there was a
history of domestic abuse reports to South Wales Police involving Joanna Michael
which had not been handled in accordance with force policy. Proper records were
not kept which could have triggered an evaluation of the risks by the Public
Protection Unit. This would not have necessarily led to a different outcome, but it
could have led to advice to Joanna and positive police interventions in relation to
Williams.
Conclusion
Joanna Michael died because Cyron Williams murdered her. Yet Joanna made a
mobile phone call to 999 to get assistance from her local police force. Joanna’s
closeness to a phone mast in Gwent led her call going to the neighbouring police
force which did not help her situation. Joanna was then failed by the two police
forces at an organisational level and failed by two individuals dealing with her
request for help.
The simple fact is that at 2.29am when Joanna called 999 an immediate police
response could have got to her house in five minutes. Because of all the various
failings the emergency response did not arrive until 2.50am, when she had already
been stabbed, probably at about 2.45am.
The IPCC cannot say that an earlier response would have saved Joanna’s life. For
all we know if the police had attended Joanna’s house at 2.35am Williams may have
just waited until the officers had left before resuming his murderous intentions. What
we can say for certain is that more could and should have been done for Joanna,
who was denied the opportunity for a prompt response which may have led to a
different outcome.
The service that Joanna received in the early hours of 5 August was below standard
and has led to both police forces deciding on disciplinary action for the two call
handlers.
The Gwent Police call handler declined to cooperate with the IPCC investigation.
She attended the arranged interview with our investigators, but relied on producing a
written statement and then declined to answer any questions put to her about the
incidents that night in August 2009. Gwent Police decided that her misconduct was
such that she would face a discipline panel on a charge of gross misconduct, for
which the outcome, if proven, can be dismissal.
The IPCC investigation found individual misconduct and failings and this is being
dealt with. The organisational failures have also been addressed through specific
learning and recommendations to improve policies and practice. These have been
accepted by both police forces and I have ensured that both police authorities for the
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two forces have our report so that they can continue the scrutiny required to ensure
that the learning is put into practice.
There are a number of wider national recommendations that we have made and I
have liaised with the IPCC commissioner with responsibility for domestic abuse to
ensure these have been passed onto the Association of Chief Police Officers and to
the National Police Improvements Agency. I have also passed the full IPCC
investigation report to Her Majesty’s Inspectorate of Constabulary, the Home Office
and the Wales Assembly Government. The full learning report is attached to this
report as an annex.
In the course of this investigation, and the other cases the IPCC has had to
investigate from the summer of 2009, there is a clear message that domestic abuse
is a high volume crime which police forces have identified as a priority in tackling.
Police policies and training all demand that officers and police staff have to properly
risk assess and keep records of each incident. We have found that this is not
happening in every case and incident. The wider learning from the five independent
investigations we started in July/August last year in Wales has led me to ensure that
each investigation took a consistent approach so that we could get at the core
elements and reoccurring issues. We also have had extensive discussions with
various experts in this area, including the Welsh Assembly Government, ACPO itself
and various women’s refuges and domestic violence experts.
This will all lead to a specific Commissioner’s Report that I will publish soon detailing
these common issues and our recommendations on police handling of domestic
abuse in Wales.
However, at the core of this case is the human tragedy that has beset Joanna
Michael’s family. Nobody set out that evening last August to deliberately handle
Joanna’s requests for help badly. The mobile phone system did not wilfully misdirect
Joanna’s 999 phone calls to the wrong police force.
But no amount of learning from this tragic case will assuage the grief that Joanna’s
family are enduring. Joanna, her children and her whole family have all been let
down by the service Joanna received on 5 August 2009.
TOM DAVIES
IPCC Commissioner for Wales
A Commissioner's Report is not an IPCC Investigation report. The purpose of a Commissioner's Report is to share with the public the
key findings and summary of the IPCC investigation, including the Commissioner's own decision making, the outcome of any legal
processes that followed from the investigation, and the learning recommendations.
The report belongs to the IPCC Commissioner who retains oversight of the investigation. The Investigation Report is provided to the
family or complainant, the police force, individual officers, and with a Coroner ahead of any Inquest. Investigation Reports are published
only in exceptional circumstances because of data protection and other legal restrictions.
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ANNEX
IPCC learning report
Key issues
• Misrouted emergency calls. This incident dealt with a misrouted call. A
misrouted call is where a member of the public makes an emergency call,
usually by mobile phone, and the call is routed by a call handling agency to
the wrong police force.
• Additions to Local and National Domestic Abuse Policy.
• Poor communication. When dealing with a misrouted call and transferring an
incident between two forces.
• Training of control room staff in relation to Domestic Abuse.
• Poor administration. In relation to the completion of PPD1 forms that should
be completed regarding reports of domestic abuse.
Misrouted calls
When a Police force receives a ‘misrouted’ call from another force via electronic
transfer or verbally, they should ring the member of the public back to inform them of
any deployment of officers to ensure that they have all the relevant information and
that the information they do have is correct.
Findings and recommendations
Currently, there seems to be no ownership internally from either of the forces
involved in relation to misrouted calls. Neither force collates figures in relation to
‘misrouted’ calls (though South Wales Police were able to obtain figures). Even
though British Telecom (the largest emergency Call Handling Agent) have a
reporting system in relation to misrouted calls this system is infrequently used. The
reality is that the number of misrouted calls in relation to the overall number of
emergency calls taken by the forces is relatively minor, however the forces have
acknowledged that time may be lost in the transfer of misrouted calls between forces
and have instigated the electronic transfer of incidents between forces. Emergency
calls, as in this incident can be time critical; time lost in transferring incidents and
also the potential for information being diluted or lost in the transfer of calls can also
be critical. It is no exaggeration to suggest that some of these calls could be matters
of life and death.
Finding 1
ACPO/NPIA Call Handling Standards guidance does not make a significant
reference to ‘misrouted’ calls and their overall steer in addressing this issue may
produce a cohesive approach between forces.
National recommendation 1
The ACPO sponsor lead for National Call Handling Standards to consider an
addition to the National Call Handling Standards Guidance with reference to
misrouted calls, this may need to include force ownership for the issue, how forces
report the issue to the CHA and how forces deal with call misrouted ‘hotspots’ so
that, if necessary, minor amendments to police boundaries can take place or mast
signals can be amended by telephone networks.
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Finding 2
South Wales Police have carried out a number of Domestic Homicide Reviews
(DHR) and they have conducted these through their review team. There is no
statutory requirement at present to conduct these reviews, but guidance produced by
the Home Office in relation to the reviews follows the review format of Serious Crime
Reviews (SCR) which take place after serious injury or death of a child. The Home
Office guidance makes reference to the fact that approximately 139 homicides a year
are domestic related. If Domestic Homicide Reviews help police forces and other
stakeholders learn from incidents where there is prior police/stakeholder contact and
potentially prevent further domestic homicides through organisational learning and
joint working, then this surely will outweigh any attributed cost to the police
force/stakeholders undertaking such reviews. The Home Office does not suggest
that Domestic Homicide Reviews should be conducted specifically by police forces,
but consideration should be given to who would be best placed to undertake a
review. It is suggested that this will largely be the police service taking the lead.
National recommendation 2
While no statutory obligation exists, it is recommended that all police forces in
England and Wales conduct Domestic Homicide Reviews as per the Home Office
guidelines as best practice until there is a statutory obligation to conduct such
reviews.
Finding 3
Domestic Homicide Reviews are not just a useful tool for local force learning and
local stakeholder learning but, collectively, if 43 police forces undertake such reviews
this could provide national learning. This in turn may influence national policy,
guidance and trends and also enhance how domestic abuse is dealt with by the
criminal justice system and effectively may nationally reduce the number of domestic
homicides.
National suggestion 1
For the ACPO sponsor lead to construct a process where learning from the Domestic
Homicide Reviews that already take place (non-statutory reviews) and any future
statutory obligation to conduct the reviews are collated, so that any trends, national
learning, and policy changes are shared with all police forces (possibly through
ACPO/NPIA). This will potentially be a significant task but could produce significant
results if domestic homicides are reduced in England and Wales.
Finding 4
The National Call Handling Standards provide forces with guidance in terms of call
grading and response times. Both forces involved in this incident follow those
national guidelines, but South Wales Police make a distinction between domestic
abuse call, when the suspect is at the address or not in terms of the call grading. If
the suspect is at the address it is an immediate response; if the suspect is not then it
is a priority response. In this incident the suspect was due to return to the property at
any time, information that was provided by the victim. It is doubtful that South Wales
Police is the only force that makes this distinction so that they can manage
resources in addressing the volume of domestic abuse calls.
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The NPIA 2008 Guidance on Investigating Domestic Abuse provides helpful
questions to be asked at the information gathering stage, which will usually be
completed by force Call Handlers. When the suspect has left the scene there are two
instructions. If the suspect has left the scene:
• Advise the caller to lock and secure the premises and to return to the
telephone;
• Take a full description of the suspect and circulate it to officers in the area.’
The victim will probably have an intimate knowledge of the suspect’s movement
which may assist the call handler in assessing any call grading, especially where
there is a distinction in domestic abuse call grades where the suspect has left the
address.
National recommendation 3
It is recommended that the NPIA add an additional question to those
aforementioned, which may assist the call grading process. If the suspect is due to
return to the address imminently (in the next 60 minutes) this information may
influence the call grading being ‘upped’ to an ‘immediate’ response. The additional
question to elicit this information could be:
‘When is the suspect due to return to the address?’
Alternatively, the NPIA in liaison with ACPO may want domestic abuse calls to come
under the national call grading guidance of ‘Immediate’ responses in their national
guidance. This may not be manageable by forces but would be more in line with the
criminal justice system’s positive action approach to domestic abuse.
Finding 5
The victim in this instance was not called back by the force deploying officers to the
scene. This could have provided the call handler with more information, i.e the
suspect’s details and the demeanour of the victim and also would have reassured
the victim that officers were attending.
National recommendation 4
It is recommended that ACPO National Call Handling Standards guidance not only
should have an insert (as per Good Practice paragraph above) regarding ‘misrouted’
calls, but also give guidance that forces should make an initial call grading based on
the information provided by the force that received the initial call (whether
information received verbally or electronically). They should also immediately call the
victim/injured party back to ensure that all the information received is correct, that
any intelligence gaps are filled and that the call has received the correct grading.
This will also reassure the caller that someone is attending and add to the ‘customer
service’ experience.
Finding 6
The NPIA 2008 Guidance on Investigating Domestic Abuse makes reference to
domestic abuse modular training. The NPIA will design and roll out the training to
forces to implement. Different modules will be relevant to different roles within
policing. Since producing the 2008 Guidance, forces with the assistance of the NPIA
have rolled out Domestic Abuse, Stalking and Harassment (DASH) training. This
training was rolled out because previous guidance (produced by CENTREX at the
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time) did not address important issues like stalking or harassment which can play a
significant part in the overall context of domestic abuse. The NPIA still has not
created the modular package referred to in their guidance. This places police forces
in some difficulty, as there are training needs in relation to domestic abuse, yet if a
force implements some training to address that need it may be superseded by the
forthcoming modular training produced by the NPIA. If forces then have to roll out
further training because ‘in-house’ training is not in line with the newly produced
NPIA modular training, then this will obviously have a financial impact on the force.
National recommendation 5
That the ACPO sponsor lead for domestic abuse, clearly outlines when the modular
training will be produced and expeditiously implement it through the NPIA. The lead
through the NPIA should also communicate the proposed ‘roll out’ to all training
departments in all police forces, and also detail what ‘stop-gap’ training would be
sufficient until the modular training is rolled out.
Finding 7
This incident involved a misrouted call. In this instance it required the operator to
establish the location of the caller and then relay the incident to the correct force. If
the call gets cut off it would require the control room operator to contact BT/Cable &
Wireless and obtain the caller co-ordinates to try and establish the caller’s location.
There are also instances where callers may not know their location as the area is
unfamiliar to them or they are lost. There is a technological system that can provide
police forces with the caller’s approximate location. This system is ALSEC/EISEC,
neither Gwent or South Wales Police currently have this system.
National suggestion 2
It is suggested that forces that do not have the ALSE/EISEC system obtain and
implement this system to assist the call taking process which it is hoped would
hopefully provide force efficiency savings. It is only a suggestion as each force will
have different incident interfaces which may not be compatible with current systems
and there will obviously be cost implications in obtaining this system.
Local recommendation(s) South Wales Police
South Wales Police Finding 1
What was made clear to the IPCC investigation, post interviewing both control room
operators, was that the call grading criterion is displayed in different formats within
the force. The IPCC obtained three different documents that had the call grading
criteria detailed on them. The documents were virtually identical apart from one call
grading criteria, that of domestic abuse where the suspect had left the scene.
One document under the priority grading list detailed:
‘Domestic abuse, where the suspect has left the address*’
The document then goes on and details what the asterisk represents.
‘Based on the individual needs and circumstances of the caller’
This document was shown to the Chief Inspector of Communications, who has
responsibility for the three force control rooms but had never seen this document.
The control room operator interviewed denied ever seeing the document. The Chief
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Inspector produced what was described as the call handlers’ ‘bible’ that all call
handlers have which also details the call criteria for priority calls. This stated:
‘Domestic abuse, where the suspect has left the address*’
The asterisk is not explained in the document. The Inspector that wrote the
document did not detail what the asterisk represented for domestic abuse calls and
this oversight was also true of another category of calls, those around sexual
offences.
This is completely unsatisfactory situation where differing documents detail different
criteria for the same type of incident, particularly considering that the forces intranet
document around call grading also differs.
South Wales Police Recommendation 1
The force to decide whether the asterisk will remain in relation to this type of call
and, if so, all the other dated documents containing different criteria for grading calls
should be deleted. The force needs to ensure there is one document that dictates
the call grading policy and that this is consistent across all the control rooms and
reflected on the force intranet.
South Wales Police Finding 2
The South Wales Police operator, after receiving the first call from Joanna via Gwent
Police, believed that when he dispatched officers they were en-route. The reality was
that they first conducted intelligence checks as they had up to an hour to attend.
When this situation was discussed with the control room dispatcher that was on shift
that evening with the SWP operator, she also believed that when officers were
‘dispatched’ that they would have been en-route.
If officers are en-route they indicate this by usually stating a code to the control room
operator, i.e. code 5 will mean en-route. If officers are not en-route and are about to
conduct other inquiries, have a meal break etc then they need to inform the control
room of this.
South Wales Police Recommendation 2
Communication between response officers and the control-room needs to improve.
All response officers that are dispatched on priority calls should inform the control
room when they are en-route, and if they do not intend to attend immediately after
dispatch then they should inform the control room of this.
South Wales Police Finding 3
Supervisory staff in the control room at South Wales Police will conduct a dip sample
of control room staffs’ calls. This dip sampling seems to take the form of one random
call per month. There is no specific monitoring of domestic abuse calls as per the
NPIA guidance (as per paragraph 102 of this report).
South Wales Police Recommendation 3
As per the NPIA guidance for investigating domestic abuse, dip sampling of
domestic abuse calls should take place through the control room supervisory staff.
This type of dip sampling is probably applicable for other specific types of incident.
The dip sample of domestic abuse incidents will ensure that call handlers are
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complying with local policy and identify whether the correct grading is being applied
to the calls.
South Wales Police Finding 4
What is clear from the Domestic Homicide Reviews that have been conducted by the
force in relation to this incident and other domestic homicides is that the
administration in relation to completing the PPD1 form has been poor. The PPD1 at
the time of the incident followed Coordinated Action Against Domestic Abuse
(CAADA) and includes a number of questions that take some time to complete with
the victim.
The recent DASH training that took place in-force will hopefully provide response
officers with a better understanding and awareness of why they are asking the victim
the questions contained in the PPD1 form.
The PPD1 requires a supervisor to sign the form off before it is sent to the Public
Protection Unit (PPU). The forms were frequently being signed off even though they
were not fully completed. The PPU were then processing the forms and the missing
details were not being addressed at this point. Whether these were not being
addressed because it was deemed too late in the process or whether the details
were not necessary to process the incident is unknown.
What is required is supervisory intervention when the forms are not fully completed.
The force also needs to have a more enhanced quality assurance process at PPU
level than they do presently.
South Wales Police Recommendation 4
Force PPU to review their quality assurance process to ensure that response officers
and their supervisors are completing the PPD1 form correctly. Where forms are not
properly completed they should be returned to the supervising officer’s Inspector via
the PPU Inspector highlighting where the forms need to be completed.
South Wales Police Suggestion 1
If is too onerous to create a new quality assurance process then it is suggested that
a quarterly review take place, where the PPU C/Inspector randomly dip samples a
number of PPD1 forms to gauge how successful the recent DASH training was in
relation to improving the quality of PPD1 input. If this does not indicate that there has
been an improvement in the completion of PPD1 forms then it is suggested that the
force revert to the original recommendation that there be a new quality assurance
process.
South Wales Police Finding 5
South Wales Police control room staff use a pro-forma for domestic abuse incidents.
It would seem that the forms were not rudimentarily completed by staff and post this
incident control room staff are now completing the pro-forma which basically acts like
an aide memoire. The questions in the pro-forma are based on the Centrex 2006
Guidance on investigating domestic abuse, which has been superseded by the NPIA
Guidance on Investigating Domestic Abuse.
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South Wales Police Recommendation 5
If the force want staff to complete the pro-forma for every domestic abuse incident
then it is recommended that this task be included in the force policy on domestic
abuse so that the decision to continue to complete these pro-formas is reinforced in
policy. Staff will then be in no doubt as to whether they should be completed or not.
It is also recommended that the pro-forma be updated to take account of the NPIA
2008 Guidance. The questions from the Centrex 2006 Guidance have not differed
significantly from the 2008 Guidance but the pro-forma should be updated to reflect
the most up to date national guidance in relation to questions that should be asked
by control room staff.
South Wales Police Finding 6
It became apparent through IPCC enquiries that when we were establishing whether
the South Wales Police control room operator had been trained in relation to
domestic abuse this could not be confirmed as the register was not kept for the
courses.
South Wales Police Recommendation 6
The Chief Inspector when made aware of this situation informed the IPCC that this
would be addressed. To ensure this is followed through, it is recommended that for
all control room training a register is kept with regard attendees and this information
is updated on force staff individual personnel records.
South Wales Police Finding 7
South Wales Police have made a distinction between domestic abuse calls where
the suspect is at the scene or not in relation to what call grading will be applied.
Domestic abuse in recent years has been made a criminal justice priority, with police
forces having positive arrest strategies, dedicated domestic abuse officers, joint
strategies with other voluntary and public funded stakeholders to address . The
Crown Prosecution Service has domestic abuse prosecution guidelines and the
Home Office has recognised that domestic abuse is more than just physical violence.
A criminologist presenting the DASH training for South Wales Police suggested that
ensuring that domestic abuse is dealt with properly and positively will act as
homicide prevention.
South Wales Police Suggestion 2
South Wales Police to consider whether the distinction between call grading where
the suspect is at the scene or has left the scene should remain. In taking positive
action in response to all domestic abuse calls it is suggested that they are all treated
as Grade 1 ‘immediate’ response unless the victim/caller requests that police do not
immediately attend.
South Wales Police Finding 8
As discussed in South Wales Finding 2 there was confusion and communication
issues around when officers are dispatched to an incident. Anecdotally, the IPCC
were told that control room staff do not generally have any contact with response
officers in person and contact is only via the radio airwaves.
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South Wales Police Suggestion 3
Control room staff have a shift pattern that allows them a regular training day. It is
suggested that to improve communication between control room staff and response
officers and to improve knowledge of each others roles, control room staff should
have ‘ride along’ with response officers on a training day. Also if operationally
possible response officers to spend one shift per year in the control room to
appreciate the role and pressures of the control room and build rapport with control
room staff.
Gwent Police Recommendation(s)
Gwent Police Finding 1
This investigation found that the Gwent operator has been in post approximately 12
years and (according to her personnel records) has never had any
training/awareness in relation to domestic abuse. It would seem that the training that
was rolled-out by Gwent Police in 2008-2009 for domestic abuse had a mixture of
staff attending, but what is apparent is that it did not include all control room staff.
Gwent Police policy in place at the time this incident occurred states that all call
handlers/FCR staff be:
‘Trained with Modules 1&2 of Centrex Responses to Domestic Violence Modular
Training Programme’
It would seem that this element of the policy has not been adhered to, as there are
control room staff who have not been trained in relation to domestic abuse. Prior to
this incident, control room training was dealt with centrally through the force training
department. Now a control room trainer is about to be appointed.
Gwent Police Recommendation 1
Any newly appointed trainer will need to conduct a training needs analysis, which
should be reviewed by the Head of Communications to ensure that the training
needs are in line with force priorities. Staff who have not been trained in key areas of
control room business (for example, domestic abuse) should be given the required
training to conduct their role as efficiently as possible, because as indicated by
national guidance the domestic abuse investigation begins as soon as the control
room operator receives the call from the victim. It should also be noted that the
domestic violence policy that was in place at the time this incident occurred indicated
that control room staff would be trained to the required standard in relation to
domestic violence.
Gwent Police Finding 2
Gwent control room staff do not have any recourse to an aide memoire in terms of
domestic abuse incidents. There is the appendix contained within Gwent Police
domestic violence policy which is accessible via the force intranet and there are a
number of questions the control room operator should ask to gather information and
assist the domestic abuse investigation. In this instance vital questions were not
asked that were contained in the force policy/national guidance.
Gwent Police Recommendation 2
It is recommended that staff have an aide memoire in relation to domestic abuse,
either linked to the computer system or paper-based to be kept with each operator’s
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computer terminal. The questions to ask the victim will reflect the questions in the
force domestic violence policy (now Public Protection Policy) or the NPIA guidance
on Investigating Domestic Abuse under the ‘information gathering’ heading.
Gwent Police Finding 3
Supervisory staff in the control room at Gwent Police conduct a dip sample of control
room staffs’ calls. This dip sampling seems to take the form of one random call per
month. There is no specific monitoring of domestic abuse calls as per the national
guidance and the IPCC investigation also questions whether the dip sampling
process is in general rigorous enough.
Gwent Police Recommendation 3
As per the NPIA guidance for investigating domestic abuse, dip sampling of
domestic abuse calls should take place through the control room supervisory staff.
This type of dip sampling is probably also applicable for other specific types of
incident. The dip sample of domestic abuse incidents will ensure that call handlers
are complying with policy, and that the correct grading is being applied to the call. As
per the national guidance, management should monitor accuracy of call grading and
supervise domestic abuse related calls.
Local suggestion Gwent Police and South Wales Police
It is suggested that Gwent Police and South Wales Police adopt the ALSEC/EISEC
system as per national suggestion 2. It will assist the forces in establishing location
of callers and potentially provide efficiency savings.
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