Dear Mr Irvine,

Thank you for your letter of 11 November 2020 enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, written following the Inquest touching upon the death of Ms. Chelsie Violet Greatorex.

In your letter you ask that I ensure the matters you have raised are considered by the Metropolitan Police Service. I should stress that the Metropolitan Police Service is operationally independent and, as such, will respond separately on the specifics of the investigation in question. I am therefore responding to the Coroner’s concerns only in so far as they relate to national policy.

I was deeply saddened to learn about the death of Ms. Greatorex and I would first like to express my deepest condolences to her family for their unimaginable loss.

Rape and sexual assault are devastating crimes. The government expects every report to be treated seriously from the point of disclosure, every victim to be treated with dignity and every investigation and prosecution to be conducted thoroughly and professionally. We want victims to have the confidence to report these crimes, knowing they will get the support they need and that everything will be done to bring offenders to justice.

That is why, along with the Ministry of Justice and the Attorney General’s Office, the Home Office is currently carrying out a review of the criminal justice response to rape. The scope of the review covers the length of the criminal justice process, from police report and investigation through to final outcome in court, so that we can take a comprehensive view of any issues that need to be addressed within the system and take action accordingly.

The review is considering several issues which related to the matters of concern you have reported. These include the provision of support for victims during the criminal justice process; the role of specialist officers with training in rape and sexual assault investigations; and causes of delay to investigations. The review will report in due course with a package of actions for cross-system improvement. I am determined that measures we take following the review will ensure more effective handling of cases and the timely delivery of justice and support for victims of these awful crimes.

Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, you may also wish to be aware that the government will shortly be publishing a first of its kind national strategy on tackling all forms of child sexual abuse. A key element of this strategy will be working across government to improve the way the criminal justice system responds to child sexual abuse and to ensure victims and survivors receive the support they deserve. We will continue to prioritise child sexual abuse as a national threat in the Strategic Policing Requirement, to empower police forces to maximise their specialist skills and expertise to tackle these crimes.

The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.

Furthermore, the government is committed to ensuring access to high quality support for victims and survivors of rape and sexual assault, wherever they live in the country and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has awarded £12m to 91 rape support centres across England and Wales to provide independent, specialist support to victims of sexual violence, including victims of child sexual abuse, an increase of £4m from 2019/20. The government has also announced that an additional £4m per year until 2022 will be invested in recruiting more Independent Sexual Violence Advisers (ISVAs) who play a vital role in informing and supporting victims at every stage of the criminal justice process.

Thank you for writing to me on this important matter. I hope that my response has demonstrated the government’s commitment to improving the criminal justice system response to rape and sexual assault and to ensuring that victims and survivors receive the support that they need.

Rt Hon Priti Patel MP Home Secretary

METROPOLITAN POLICE PROFESSIONALISM HQ Deputy Assistant Commissioner Mr Graeme Irvine New Scotland Yard Area Coroner for East London, Victoria Embankment Walthamstow Coroner's Court, London Queens Road, SWIA 2JL Walthamstow, E17 8QP Email: Tel_ Jr 101 Your ref: Our ref: Date: 30th December 2020 Dbe-ilL Imiae am the Deputy Assistant Commissioner (DAC) for Professionalism in the Metropolitan Police Service (MPS) and am responding on behalf of the Commissioner of Police of the Metropolis in response to your Regulation 28 Report to Prevent Future Deaths dated 12th November 2020_ Your report was sent following the conclusion of the Inquest into the death of Ms Chelsie Greatorex: On 1gth June 2020, the Directorate of Professional Standards Specialist Investigation Unit (DPS SIU) conducted an investigation into police contact with Ms Greatorex to her death on 10th March
2020. A report was compiled various sources of evidence, including, but not limited to, the statements of the investigating officer crime reports, Computer Aided Despatch (CAD) messages and Missing Persons & Related Linked Indices (Merlin) reports_ This report will be referred to in this letter when addressing the areas you have raised. The response to the matters of concern is as follows: Evidence heard in the inquest suggested Ms Greatorex felt anxiety regarding her role as complainant in a sexual assault trial The DPS SIU Investigation Report details a number of occasions when Ms Greatorex reached out to the investigating officer about feeling anxious and low: They appear to have formed trusting relationship and when Ms Greatorex appeared to become particularly the investigating officer offered Ms Greatorex advice and a referral to a support agency. However, Ms Greatorex reassured the investigating officer that she was fine_ On the Ms Greatorex was informed of the date of the trial, there was little to suggest to the officer that she was feeling very Iow or in need of any further support other than what would be normally considered during a difficult time for any complainant in a case such as this_ prior using Iow, day

To further support Ms Greatorex; on the approach to the trial an application was made to the court for "special measures" of which know you will be familiar. This process would have included pre-trial visit to the court; a private room and further support at the court In order to provide additional support for victims andlor witnesses throughout the entire investigative process, the MPS has introduced a THRIVE+ vulnerability assessment which is currently trialled and is anticipated to be rolled out across the MPS in April 2021_ It is a set of principles and a framework to assess the type of policing response or investigation required for particular set of circumstances. THRIVE covers: Threat Harm Risk Investigation Vulnerability Engagement Prevention/Intervention. The framework is a tool which aligns to and enhances the National Decision Model and includes the assessment and ongoing review of risk during investigations It also provides a common language around risk to improve information sharing and decision-making: Despite the fact that Ms Greatorex was a child when the events of the allegation took place the investigation was not conducted by a specialist officer or team Delays in the investigation were identified: Despite naming the suspect and their place of study, no interview took place for over 3 months A decision to prosecute was not arrived at until late December 2019 court hearing was not listed until January 2020 The allegation Ms Greatorex made was considered at the outset by specialist officers and it was decided that due to the non-complex nature of the investigation, it would remain with Response Team officer to investigate The MPS General Investigation Policy states that 'Where there is requirement for ownership of crime investigations by the initial investigating officer, there may be occasions where the characteristics of specific investigations identify themselves as serious andlor complex It is important that this is identified as soon as possible so that the most appropriate investigating unit is assigned to that investigation dependent on that seriousness andlor complexity: If serious andlor complex characteristics are present, then CID should be approached to take on that investigation The policy provides details of types of crime that are considered complex and_ 'If the crime type is not listed above and there are no serious Or complex characteristics; then the responsibility for further investigation must stay with the response team officer'. In this instance , the crime was retained by the Response Officer to investigate. The MPS recognises that as the investigation was not considered complex; it should have been completed in quicker timeframe_ The MPS have therefore made improvements in the supervision and team structures of response teams to support less experienced officers with their investigations A Response Support Team was set up on North East Basic Command Unit on 23rd September 2020 and blends together resources from Emergency Response Policing Teams, Local Resolution Teams, Criminal Investigation Departments and probationary officers and their mentors_ The Response Support Team functions as training unit and allows for steady improvement of officers investigative skills and point of contact for advice_ The observations about the length of the investigation and failure of management systems to adequately prioritise Ms Greatorex's case are being addressed with the introduction of new product; the vulnerability tool, which has been developed for Basic Command Units monthly Offender Management Meetings which prioritise outstanding named suspect cases when the victim has been identified as being the subject of some form of vulnerability. This allows for management intervention and looks across all offence types to identify cases where progress should be prioritised for the benefit of victims where an element of vulnerability has been identified. The vulnerability tool highlights those cases where the suspect has not been arrested andlor interviewed after two months and involves a vulnerable victim; for example, a person who is mentally unwell, who has physical impairment_ is under the age of 18 years; this is not an exhaustive list Therefore, by using the vulnerability tool, it is intended that similar cases to this will be identified as requiring management intervention and prioritisation. being Team

The timeliness from when the decision to prosecute and the court hearing lies with the CPS and Her Majesty's Courts Service (HMCS): The suspect for this allegation was interviewed on 5th November 2019 leading to a submission of the evidential file to the Crown Prosecution Service (CPS) on 26th November 2019. The investigating officer made further contact with the CPS on 18th December 2019 regarding the decision on charging authority and seeking to expedite the case The CPS authority was granted on 27th December 2019 The suspect was served charges on 2nd January 2020 with first court appearance provided for the end of the month: When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of borough psychologist support service The investigating officer stated throughout the investigation that her contact with Ms Greatorex was either in person or by telephone as Ms Greatorex's expressed preferred method of contact Ms Greatorex would email the investigating officer asking her to call her; but was aware that due to her shift pattern the officer may not be able to call her back for a few days: The investigating officer was of the understanding that Ms Greatorex was also receiving support from her college through weekly meetings with guidance counsellor: When Ms Greatorex made the officer aware that she was feeling anxious as she was getting into trouble at college for leaving doors open, the officer agreed to speak with the staff about this which she did. The DPS SIU Investigation Report outlines the occasion when Ms Greatorex had emailed the officer on` 4th March 2020 as she had felt little low and wanted someone to speak to. The investigating officer had previously told Ms Greatorex that she could contact her at any time by email and that she would respond as soon as she was able. The officer returned the call on 7th March but reached her voicemail On 9th March the investigating officer checked her emails from home and saw that a court date had been arranged for January 2021. The officer then telephoned Ms Greatorex to inform her. The e-mail of 4th March 2020 was discussed and Ms Greatorex explained that at the time of writing the email she had just had one of those but everything was fine now: The officer asked her what she meant by feeling low and Ms Greatorex said that she had been worried about the case and what it would entail: The officer asked if she had someone she could speak to if she felt low and Ms Greatorex said she had an aunt she saw and spoke to regularly: The officer explained to Ms Greatorex that she was always welcome to talk to her but that she may not be the best person to help her with her mental health so she would email her details for Newham Talking Therapies (NTT) The officer also offered to refer Ms Greatorex other agencies, which she declined: Ms Greatorex said she was happy speaking to her aunt and would contact NTT if required. The conversation ended with Ms Greatorex in good spirits, talking about a recent exam and saying that she would be in contact soon: The investigating officer provided Greatorex with the NTT details despite what was said in the conversation_ During this conversation, the officer said in her statement that it did not appear to her that Ms Greatorex was in a mental health crisis and her responses led the investigating officer to think that the low feeling had passed and, although worried about the case, there was network of support in place_ The MPS is committed to progress learning from instances of death by suicide involving victims and suspects and further develop the response to these. A small team of dedicated officers leading this work has focused on the delivery of key areas. The team is developing a Suicide Prevention Policy Document and Toolkit: The publication of this policy is step in developing our co-ordinated strategy to suicide prevention. The policy will draw together information on suicide prevention, support services, risk indicators, contacts and best practice. It will be accompanied by toolkit providing easy to access guidance and advice from signposting support services to identifying partners_ A draft external Suicide Prevention Policy is due to be drafted by the end of December 2020 prior to going through the MPS's internal policy development process_ In addition to the policy publication, the suicide prevention team is committed to improving the training and guidance available to all officers and staff. An investigative standards' document is under development and is designed as an easy to follow key points to consider document for police first responders This will enhance knowledge and understanding across the entire service and build on the additional guidance that is already used by some teams where death by suicide is considered higher risk i.e. Custody, Online Child Sexual Abuse. days Ms key key

The MPS Suicide Prevention Team is also meeting with other police forces to learn and share good practice In Conclusion would like to express my condolences to the family of Ms Greatorex The MPS is committed to supporting all victims of crime and assisting them to get justice where possible: recognise that this can't happen unless complainants and victims are adequately supported throughout what can often be a challenging investigation and criminal justice process. hope this provides you with the reassurance that the MPS has considered and addressed the areas of concern that you have raised Please do not hesitate to contact me should you have any queries;