Dear Mr Smith

I am the Assistant Commissioner for the Met Ops Chief Officer Team in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the MPS in your Report to Prevent Future Deaths dated 19th June 2023.

On behalf of the MPS may I first of all express my condolences to the family and friends of Nicholas Leger, our thoughts and sympathies are very much with them.

The MPS has acknowledged and reviewed all the matters of concern raised in your Regulation 28 Report and responds as follows:

The Coroner’s “Matters of Concern”

The Prevention of Future Deaths report records:-

It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).

MPS Response

The MPS process for issuing a Postal Charge Requisition (“PCR”) is for the Officer in the Case (“OIC”) to gain charging authority from the Crown Prosecution Service (“CPS”), who will then request a PCR via the MPS CONNECT system (database for recording case file progression - previously known as the COPA system in March 2022). This is then transferred to the Case Management Team (“CMT”) who complete the PCR administrative process, sending it directly to the recipient. Prior to this, no additional checks are completed on the information or the recipient and no advance warning of this PCR is given by the CMT.

At all stages prior to this request, the OIC is able to communicate to the CMT via email, telephone and the CONNECT file, that the suspect may be vulnerable because of their mental health. The OIC can then decide whether to serve the PCR by delivering it by hand direct to that person. This does not necessarily need to be due to the individual being in a high risk offence category. The delivery of this PCR can be communicated prior to the event by the OIC and it would be reasonable to expect in certain circumstances, following any highlighted risk, that this action would be taken, however, there is currently no compulsory process for this.

There are currently no risk assessment questions on the CONNECT file that the CMT have sight of or access to. As stated in the report, the decision whether an individual is considered to be in a high-risk offence category, which would suggest the benefit of personal PCR delivery, is reliant on information regarding their mental health and risk of self-harm or suicide, coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information outside of the custody environment.

It is acknowledged that being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can have a detrimental effect on an individual’s mental health, and certain types of allegation, such as a sexual allegation, may carry a higher risk. It is recognised that there is currently no formal process for assessing an individual’s mental health or risk of suicide or self-harm at the time of delivery of a PCR.

For those persons detained in custody suites, custody officers complete a risk assessment on CONNECT prior to release. For sexual offences, an additional risk assessment is completed by the investigation team. A Voluntary Attendance Assessment and log is completed for all suspects who attend for voluntary interviews under caution and this includes questions on mental health, self-harm and suicide.

Following this Prevention of Future Deaths report, a proposal will be made for the implementation of a new policy requiring a risk assessment to be completed by the OIC, no earlier than fourteen days prior to issuing the PCR. This would build on the intelligence already gathered through the relationship between the OIC and the suspect, including any risk assessments completed at the time of their arrest/detention/voluntary interview under caution and by the Custody Sergeant upon release from custody. This would then form the basis of a decision as to whether to post or serve the PCR in person.

Due to the volume of work required, this policy would be restricted to suspects charged with a recordable offence.

This assessment will be supervised by line management and form part of the PCR process. This will include provision for risk management and mitigation controls.

The design will commence in partnership with investigation and safeguarding teams to ensure consistency and viability with the expectation that it will be implemented by April 2024.

It is expected that when a suspect for a criminal offence is released on bail or Released Under Investigation (RUI), the OIC should maintain regular contact. Ordinarily, there should not routinely be long periods of time where no contact has been made between the OIC and suspect without further risk assessment. Unfortunately due to the implementation of RUI, there has previously been a substantial period of time between leaving custody and receiving a PCR. However, due to a change in legislation in 2022, it is anticipated that RUI may be used less frequently. Instead, the intention of the new legislation is to increase the use of pre-charge bail in every case where it is necessary and proportionate to do so. The consequences are anticipated to be a reduction in the numbers of suspects receiving a PCR as suspects on pre-charge bail will be charged on their return to custody.

Please do not hesitate to contact me should you have any queries.

Dear Mr Smith, Thank you for your letter dated 8th June 2023 regarding the death of Mr Nicholas Leger which occurred on the 20th February 2023. We were saddened to hear of the circumstances and the loss felt by Mr Leger’s family and friends. These cases are always tragic and it is incumbent on all of us to ensure that lessons are learned. We would like to assure you that we take the recommendations in your report extremely seriously and will ensure that the learning from this incident will be incorporated into our training and guidance. Thank you for your work and for identifying matters of concern. Your report gives us the opportunity to reflect on the circumstances and consider what action we might be able to take to prevent future deaths. You report covers the following matters of concern:

• The welfare and support offered to Mr Leger by the Metropolitan Police
• The process for when a person who has been released under investigation (RUI) is charged, resulting in postal charge requisition (PCR)
• The process for assessing an individual’s mental health and/or risk of suicide or self- harm at the time of delivery of a PCR.

You conclude that in the absence of a formal mechanism to assess an individual’s mental health and risk of suicide or self-harm at the point of issuing a PCR, you believe there is an obvious risk of individuals taking their own lives.

We have carefully considered the information you have provided.

It is important to recognise that the offence under investigation carries a maximum life sentence and we infer that this was a very serious allegation and that there would have been significant concerns about harm that had been caused by the alleged offence and the risks of future harm. Investigators must consider the needs of all involved in investigations and this can sometimes be a difficult balancing act, taking account of the fact that, at this stage, the person under investigation has not been convicted.

Pre Charge Bail and Released Under Investigation The law regarding pre charge bail has significantly changed following the Police, Crime, Sentencing and Courts Act 2022. Significant changes to pre charge bail were introduced in October 2022. Whilst the precise offence in question is not mentioned, we consider that it is far less likely that a case such as Mr Leger’s would result in a person being on RUI under today’s legislation.

The Police, Crime, Sentencing and Courts Act 2022 (PCSC) removed the previous presumption against bail, replacing it with a neutral position to encourage the use of pre-charge bail where it is necessary and proportionate in all of the circumstances of the case. It amended the police ranks of authority, requiring less seniority in rank, and changed the duration of bail periods, including extending the initial bail period to three months, from 28 days, in standard cases. To provide further protection for victims, the PCSC introduced a duty to seek the views of victims when imposing or varying bail conditions. The consequences of these changes – no presumption against the use of pre charge bail, lowering of the ranks to authorise its use and the extension of the bail periods means that pre charge bail is much more likely to have been continued had the investigation been commenced after October 2022.

The College of Policing produced Statutory Guidance which supports the legislative amendments. The Statutory Guidance can be found here. The following guidance is particularly relevant based on the information provided.

If there is a risk of serious harm to the victim(s), witness(es), suspect or public, bail must be considered in conjunction with other protective measures. Bail with conditions should always be considered in any domestic or sexual abuse cases.1

In the unlikely event pre charge bail did end and convert to RUI, the statutory guidance provides further advice and instruction.

The threat, risk and potential for future harm associated with the investigation must be proportionately managed, taking into consideration the safeguarding of all persons linked to the investigation.

Onward suspect management and welfare assessment will be the responsibility of the investigator, with oversight from their supervisor. There should be a clear plan in place, linked with the likely progress of the investigation.

Forces are recommended to establish a formal mechanism, prior to release, for notifying suspects that they have been RUI and explaining what this means.

Due to these changes, the likely scenario now is that Mr Leger would be on bail and that he would be recalled to custody to answer charge. Following a new risk assessment, there would be the opportunity to refer him to NHS liaison and diversion services should there be any indication of any health need, including any concerns about mental ill-health and that would include indications of self-harm or suicide.

The law has significantly altered since Mr Leger was investigated, bailed and RUI’d. Detailed Statutory Guidance was made available earlier this year, which was accompanied with e-

1 Pre Charge Bail, Statutory Guidance, March 2023, College of Policing - Pre-charge bail - Statutory guidance (publishing.service.gov.uk), Page 9 para 6.4

learning and a communications plan and roll out, supported by a number of knowledge products to assist forces to implement the change. We take the view that this should make a significant difference to the number of suspects on RUI and we have been clear about how forces should manage those who are on RUI and pre charge bail, including specific guidance on safeguarding those subject to RUI.

Pre release risk assessments Bringing Mr Leger into the police station on a ‘voluntary attendance’ in November 2022 would have been considered a way of progressing the investigation in the least intrusive way, seeking to reduce the impact on him.

There is specific College guidance on risk assessments for those released from custody, including a specific module on the higher risks associated with those under investigation for possession of child sexual abuse material – the risks for this cohort of detainees are higher with them comprising around half of all post release suicides. Conclusion It is unlikely that someone released on bail for sexual offences would now revert to RUI. This means that they would be recalled to custody for charge, where a pre-release risk assessment can be completed, for which there is full guidance. There is specific custody training aimed at reducing the risks of post detention suicides.

I hope this description of how current pre charge bail arrangements work reassures you that should a similar case arise, there would be further opportunities to assess a person’s risk of suicide.