Lewis Johnson
PFD Report
All Responded
Ref: 2025-0242
All 1 response received
· Deadline: 18 Jul 2025
Response Status
Responses
1 of 1
56-Day Deadline
18 Jul 2025
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursing vehicle and the subject vehicle at points when the two appeared to be closer together.
Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit.
Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit.
Responses
The IOPC is updating its internal guidance for lead investigators to ensure consideration is given to securing full Forensic Collision Investigation Reports and to require investigators to consider distance calculations in the terms of reference, with the updated guidance available within the next fortnight.
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View full response
Dear Ms Hassell
Regulation 28 Prevention of Future Death Reports arising from the inquest touching on the death of Lewis Dean Johnson
Thank you for your Preventing Future Deaths Report arising from the inquest into the death of Mr Lewis Dean Johnson. I also thank you for the extension you have kindly granted to allow the IOPC to respond. We have carefully considered your report and set out our response below in relation to the following concern:
At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursing vehicle and the subject vehicle at points when the two appeared to be closer together. Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit.
The IOPC is committed to ensuring that whenever we carry out an independent investigation into a death or serious injury, our investigation is thorough and evidence- based with a clear focus on learning and accountability.
We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.
With regards to the investigation into the tragic death of Mr Johnson on 9 February 2016, the IOPC declared an independent investigation on 12 February 2016 and as part of this investigation, it decided to instruct a Forensic Collision Investigator to draft a report. This report indicates that the terms of reference were agreed between the Forensic Collision Investigator and the IOPC but they are then not quoted within the investigator’s report.
OFFICIAL
2 During the investigation, we also instructed an NPCC expert and within those terms of reference they refer to the Forensic Collision Investigator being asked to prepare a report to contain information including “distances”. The Forensic Collision Investigator report provides a detailed CCTV analysis that discusses the distance between Mr Johnson’s motorcycle and the police car in seconds but does not provide a measured distance in metres. The expert does not comment on whether this was possible or not. A copy of both documents are provided with this response.
Actions to be taken / Organisational Learning
Considerable time has passed since Mr Johnson’s death and there have been numerous developments in roads policing and investigations into deaths and serious injuries arising from police pursuits since 2016.
The Police, Crime, Sentencing and Courts Act 2022 introduced a new legal test to assess the standard of driving of a police officer for the offences of dangerous and careless driving. In determining whether an offence has been committed, the standard of driving is compared to that of a competent and careful constable who has undertaken the relevant prescribed training. Under the new test, evidence of a police officer’s training and the assessment of a police driver training expert are required to determine whether the driving fell below (or far below) the standard expected of a competent and careful constable who has undertaken the same prescribed training. The IOPC now has protocols in place with the NPCC and College of Policing for the IOPC to instruct subject matter experts from a panel organised by the NPCC who can provide an expert opinion on compliance with policy, procedure and training.
In addition, in all IOPC investigations into fatal road traffic incidents, the IOPC may make representations for a full Forensic Collision Investigation Report to be completed by a Forensic Collision Investigator, or we may commission one from an independent source.
The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straight forward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.
We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.
In the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made. In instances where we feel it is appropriate to secure a streamlined collision investigation report, we will set out the minimum standards we expect for that report, to ensure all relevant information is secured.
OFFICIAL
3
I trust that the information provided clarifies our role and offers reassurance regarding the matters raised. We are committed to upholding the principles of impartiality and independence, which are fundamental to the integrity of our investigative processes.
Regulation 28 Prevention of Future Death Reports arising from the inquest touching on the death of Lewis Dean Johnson
Thank you for your Preventing Future Deaths Report arising from the inquest into the death of Mr Lewis Dean Johnson. I also thank you for the extension you have kindly granted to allow the IOPC to respond. We have carefully considered your report and set out our response below in relation to the following concern:
At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursing vehicle and the subject vehicle at points when the two appeared to be closer together. Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit.
The IOPC is committed to ensuring that whenever we carry out an independent investigation into a death or serious injury, our investigation is thorough and evidence- based with a clear focus on learning and accountability.
We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.
With regards to the investigation into the tragic death of Mr Johnson on 9 February 2016, the IOPC declared an independent investigation on 12 February 2016 and as part of this investigation, it decided to instruct a Forensic Collision Investigator to draft a report. This report indicates that the terms of reference were agreed between the Forensic Collision Investigator and the IOPC but they are then not quoted within the investigator’s report.
OFFICIAL
2 During the investigation, we also instructed an NPCC expert and within those terms of reference they refer to the Forensic Collision Investigator being asked to prepare a report to contain information including “distances”. The Forensic Collision Investigator report provides a detailed CCTV analysis that discusses the distance between Mr Johnson’s motorcycle and the police car in seconds but does not provide a measured distance in metres. The expert does not comment on whether this was possible or not. A copy of both documents are provided with this response.
Actions to be taken / Organisational Learning
Considerable time has passed since Mr Johnson’s death and there have been numerous developments in roads policing and investigations into deaths and serious injuries arising from police pursuits since 2016.
The Police, Crime, Sentencing and Courts Act 2022 introduced a new legal test to assess the standard of driving of a police officer for the offences of dangerous and careless driving. In determining whether an offence has been committed, the standard of driving is compared to that of a competent and careful constable who has undertaken the relevant prescribed training. Under the new test, evidence of a police officer’s training and the assessment of a police driver training expert are required to determine whether the driving fell below (or far below) the standard expected of a competent and careful constable who has undertaken the same prescribed training. The IOPC now has protocols in place with the NPCC and College of Policing for the IOPC to instruct subject matter experts from a panel organised by the NPCC who can provide an expert opinion on compliance with policy, procedure and training.
In addition, in all IOPC investigations into fatal road traffic incidents, the IOPC may make representations for a full Forensic Collision Investigation Report to be completed by a Forensic Collision Investigator, or we may commission one from an independent source.
The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straight forward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.
We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.
In the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made. In instances where we feel it is appropriate to secure a streamlined collision investigation report, we will set out the minimum standards we expect for that report, to ensure all relevant information is secured.
OFFICIAL
3
I trust that the information provided clarifies our role and offers reassurance regarding the matters raised. We are committed to upholding the principles of impartiality and independence, which are fundamental to the integrity of our investigative processes.
Report Sections
Investigation and Inquest
On 12 February 2016, I commenced an investigation into the death of Lewis Johnson aged 18 years. The investigation concluded at the end of the inquest yesterday. (There were several reasons unconnected with the inquest why there was such a delay in the conclusion.)
The jury made a narrative determination at inquest, a copy of which I attach.
The jury made a narrative determination at inquest, a copy of which I attach.
Circumstances of the Death
Lewis Johnson died as a consequence of a road traffic collision at Clapton Common A107 in London on 9 February 2016, following a police pursuit. He was riding a motorcycle and had a pillion passenger.
Copies Sent To
Metropolitan Police Service Commissioner
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.