Dear Ma’am,

I write on behalf of Essex Police in response to your Regulation 28 report to Prevent Future Deaths following the inquest touching upon the death of Ms Aminata Coulibaly. This letter acknowledges the concerns you have raised and sets out the action already taken alongside measures Essex Police will take. Your report identified risks which I have summarised into four areas:
1. Victim communications and information-sharing: emails sent by Ms Coulibaly on 22nd June 2022 and her phone call on 24th June 2022 were not uploaded to the Essex Police Athena system or shared with the Essex Partnership University NHS Foundation Trust (EPUT).
2. Contact Management Command (formally known as Force Control Room (FCR)) recording and escalation: Contact Handlers did not consistently record information provided by EPUT nor clarify indicators to support THRIVE assessment and appropriate deployment.
3. Investigation management standards: the absence of a Case Action Plan, poor suspect interviews, deficiencies in hate-crime investigative supervision and victim care, contributing to Victims’ Code non-adherence and Ms Coulibaly being incorrectly told her case was closed.

Chief Superintendent Harlow Police Station The High Essex CM20 1HG 13th January 2026 Ms Sonia Hayes HM Area Coroner for Essex Seax House Ground Floor Essex County Council Victoria Road South CM1 1LX

4. Safeguarding pathways and referrals: interaction between police and health/social care services did not consistently translate concern into formal safeguarding referrals and coordinated support. We accept that the above areas required improvement. In addition to the evidence provided during the inquest hearing, I will detail the action Essex Police has taken since 2022 to improve and address your concerns.
1. Victim Communications and Information-Sharing Essex Police places great importance on the service we provide to all victims, especially those who are vulnerable, and this is central to our Force Plan set by Chief Constable Harrington.
• Essex Police must adhere to the Victims Code, and the force has established extensive governance, data audit, performance compliance, and development of best practise to achieve this, which has enhanced victim communication since 2022. This includes Chief Officer oversight, led by Assistant Chief Constable who chairs a force Victims Board, during which compliance of each Essex Police command is inspected. The Force has a Victims Manager whose role includes the development of best practise to improve victim communication, including the introduction since 2022 of innovative practises such as the Victim Engagement Portal, which improves our communication with victims. We have also launched a victim survey, capturing the victims voice and their experience of our service. This data will be incorporated into a data dashboard, allowing us to review what victims are saying and improve our service.
• Essex Police has updated policy and procedure to direct action to be taken to investigate crime, support victims, and share information. Of key importance is procedure B0602 Investigation of Crime, updated in September 2025 which states at
3.7: “Essex Police is committed to the protection of vulnerable adults and children. Although every situation is different it is recognised that abuse can take many forms. Abuse might consist of a single act or repeated acts of abuse. Safeguarding considerations should be constantly re-assessed throughout the life of the investigation as enquiries progress.”

“Prior to filing any Athena record, the officer owning this record is responsible for completing the referral to the appropriate department or agency. Failure to do this must be justified on the Athena record. Copies of all referral documents and e-mails must be uploaded to the Athena investigation. An outcome for all referrals must be obtained and documented on Athena detailing what action has been taken to advance the welfare or protection of victims and where appropriate witnesses. Athena investigations should not be closed without such an outcome.”
• As discussed during the inquest hearing, the Officer in the Case for Ms Coulibaly`s crime on 13th March 2022, did not update the Athena log with relevant contact and updates nor inform EPUT. This has been addressed with them and their supervisor by reflective practise and learning which has been completed.
• Following this inquest, a working group of senior leaders and operational experts has been formed to ensure our victim update and crime closure procedures are clear and achievable for officers and staff as to what contact to and from victims must be recorded and where on Athena. This work will be completed by the end of February
2026.
• For repeat medium or high-risk victims of Hate Crime, such as Ms Coulibaly, Essex Police provide tailored support through dedicated Hate Crime Officers. Victims are offered clear reporting routes, safeguarding advice, and signposting to partner agencies such as Victim Support and community-based organisations. Where appropriate, referrals are made to statutory partners such as Social Services and Fire, for emotional and practical assistance. We signpost victims to other appropriate services such as Tell Mama, CST, Hate Incident Report Centres and Essex Restorative and Mediation Services. Our approach prioritises empathy, confidentiality, and building trust, ensuring victims receive comprehensive care throughout the criminal justice process. This victim support is documented in forces HC2 support booklet which is provided to victims of Hate Crime. There is a data performance process established through our Victim Engagement Portal to check the HC2 support booklet is provided.

2. Contact Management Command Recording and Escalation Our Contact Management Command (CMC) deals with all emergency and non-emergency contact from the public and partner agencies. This is a complex, high volume and high-risk area of policing, through which we fulfil our initial assessment and response and provide the

best service possible. Our Quality of Service team which was referred to during the inquest hearing due to the contact they had with Ms Coulibaly, was disbanded as part of efficiency savings several years ago, and all public contact is now led within the CMC. This command has considered the risk identified by HM Coroner and have completed the following since 2022 to address this:
• The Concern for Welfare policy which was detailed during the inquest hearing and sets out the police response to such calls has been superseded by the Right Care, Right Person (RCRP) policy D 0800 and procedures D 0801 to 803. These came into effect in early 2024 and follows national guidance which was developed with partner agencies including the NHS. These procedures establish that the right agency deals at first point of contact, and then throughout an incident. This provides clarity to Essex Police officers and staff to make operational decisions when responding to call for service involving medical support, physical, and mental health, from members of the public or partner agencies.
• Procedure - D 0801 RCRP – Concern for Welfare, provides clarity to the police and partners on when a concern for welfare request will, and will not, become a police responsibility to respond. This sets out that police may owe a duty of care, and therefore may have a duty to respond where:
1. There is a real and immediate risk or threat of harm to life or property:
2. The vulnerable person or child is suffering or are at risk of suffering immediate and serious significant harm as set out in Section 47 of the Children’s Act 1989 and further described in the SET Safeguarding and Child Protection Procedure 2022.
3. It is reasonably believed that a crime has been committed or is about to be committed.
4. Attendance of a police officer is necessary to prevent a Breach of the Peace.

• Within the CMC, this change in policy has been supported by the introduction of new incident headers on our Command and Control system (STORM) aligned to these changes, with a clear call script for Contact Handlers to utilise when dealing with such calls for service, whether by the public or partner agencies, which guides them to a proposed decision and outcome.
• This procedure makes clear that the National Decision Making model (NDM) underpinned by the THRIVE risk assessment tool will be used by staff to assess risk.

The document describes the elements of the THRIVE risk assessment, and specifically in relation to vulnerability, highlights:
1. Vulnerability is defined as: “a person is vulnerable if, as a result of their situation or circumstances, they are unable to take care or protect themselves, or others from harm or exploitation”;
2. A person may be vulnerable due to them being a Victim of crime, or due to their personal situation or may be vulnerable due to their current circumstances, at the time of the incident;
3. When assessing vulnerability, the following factors may indicate someone is vulnerable:
1. Family Circumstances;
2. Personal Circumstances;
3. Health & Disability;
4. Equality and Diversity;
5. Economic Circumstances;
6. Repeat Victimisation. The procedure highlights that any specific threat should be recorded verbatim and that where circumstances or information which is likely to alter the risk assessment changes, and the incident is not the primary responsibility of the police, it is incumbent on staff to ensure the changes in circumstances/risk assessment are passed to the relevant authority.
• This procedure also makes clear that any re-grading of the risk or response because of changes to circumstances or information must be recorded on the incident, with a re-THRIVE assessment, and any downgrade of response level must be ratified by a supervisor. To ensure these procedures are understood and consistently delivered by operational officers and staff in our Control Centre, the following has been implemented:
• CMC training programmes include the above policy and procedures as part of the new recruit programme for Contact Officers and staff.
• There is specific training in relation to incident recording and use of the NDM and THRIVE.
• Call scripts (as referenced above) have been introduced for RCRP incidents to guide Contact Handlers through incident handling to identify whether police should or

should adopt responsibility and attend. Ensuring only those incidents which are policy compliant and require an immediate response are adopted, or the caller/agency advised and directed to more appropriate agencies accordingly.
• Introduction of Continual Professional Development (CPD) days for Contact staff have included refresher inputs on RCRP, THRIVE, and policy compliance, including re-thrive, incident response grade changes and escalation processes, and including supervisory oversight and responsibility.
• Strategic oversight is managed by the Assistant Chief Constable led RCRP & Mental Health Oversight Board. This facilitates engagement with partner agencies from across the county.
• Call script compliance is included as part of Contact Management Quality and Compliance Checks (QCCs) reported on monthly to the Command Team.
• Numbers of RCRP incidents and dip checking of content/policy compliance are additionally reviewed as part of the Contact Management Daily Management Meeting performance metrics, by the Force Incident Manager Inspector, and the Command Duty Officer. Essex Police has an escalation process detailed in our Command and Control of Incidents procedure at 3.7.2, to ensure decisions made by a member of staff that Essex Police will not attend a call for service, or to change the attendance grading, are reviewed by a supervisor to ensure this is appropriate and complies with procedure. The Command and Control of Incidents procedure states that if there is no agreement between the Essex Police supervisor and another agency requesting our attendance, this will be raised to the Force Incident Manager for review. Failing resolution at that point, the matter will be referred to a higher rank for a final decision.
3. Investigation Management Standards The investigation of crime is a core function of policing and one we continually aspire to improve. In relation to the risks raised by HM Coroner, the following action has been taken since 2022.
• Essex Police has made notable progress in improving Case Action Plan (CAP) compliance through the work of the Investigations Improvement Board (IIB). The board has driven initiatives such as the Volume Crime Investigation Improvement Plan and the deployment of investigation support interventions, which resulted in approximately a 20% increase in audit and inspection compliance. The compliance

rate in October 2025 was 90.8%. These improvements were supported by locally identified coaches and structured interventions for acting sergeants, ensuring consistency in investigative standards. Additionally, the board has focused on enhancing investigative workloads, screening strategies, and CAP adherence, aligning processes with national recommendations and performance benchmarks.
• Governance of compliance is underpinned by a robust framework managed through the IIB’s Terms of Reference which is overseen by ACC who has responsibility for crime. The governance structure ensures accountability at multiple levels, with Superintendents tasked to implement local oversight and discharge recommendations from the Audit and Inspection team. The IIB agenda integrates reviews of bail, crime, and victim care obligations, shifting from a purely compliance tool to a quality assurance measure. Regular audits, dip-sampling, and performance meetings feed into this governance model, supported by clear direction from senior leadership to maintain standards and embed continuous improvement across the force.
• Essex Police now has a Chief Superintendent who leads a Volume Crime Improvement Programme. This has seen activity which has supported the improvement of investigation standards. Examples of their completed work include the use of a team of two Detective Sergeants and four Constables who worked in each area of the force to raise knowledge and standards. Training films have been produced to reinforce key skills, assist investigative standards, and workload management. A central repository is being designed for all investigative best practice.
• Regarding the specific investigation of Hate Crimes, the force has a dedicated Chief Superintendent with strategic responsibility for our Hate Crime Policy & Procedure and liaison with other agencies and partners. They are supported by dedicated Hate Crime Officers. This Chief Superintendent chairs a Hate Crime Delivery Board in which they review performance and ensure operational compliance with our Hate Crime Procedure.
• Training inputs have been provided to Neighbourhood Policing Team Officers (who investigate medium and high-risk Hate Crime) to support their investigation standards and victim care. These will take place again during 2026.
• The Force has specific Hate Crime Policy & Procedure, which is updated every year, last in December 2025. The force completes monthly dip checks of all investigation types through Inspectors which will include Hate Crimes. The results of these are

reviewed at the Force IIB. In addition, additional Hate Crime audits commenced on 5th January 2026 which are reported to the Hate Crime Delivery Board.

4. Safeguarding Pathways and Referrals Since 2022, Essex Police have established a Mental Health Triage team to improve safeguarding pathways and referrals. They are a strategic department within our Strategic Vulnerability Centre (SVC) that works with partners to provide a holistic overview of mental health across Essex and exists to bridge the gap between the police and partner agencies. They work with partners regarding mental health policies and procedures to ensure they are collaborative and fit for purpose. This has been achieved by:
• Identifying and supporting individuals of concern where mental health is a factor. The team develop multi-agency tactical plans, that aim to mitigate the risk of this individual, both to themselves and the wider public. This is managed through a Mental Health Risk Management Board, which is the tactical forum to discuss individual cases.
• Assisting with training regarding mental health matters to ensure officers and staff are kept up to date with the latest updates in law, policy and notable news events that may highlight learning points for the force and ongoing development.
• Researching and identifying best practice from other Police Forces and NHS Trusts around the UK to learn, share and implement to continually enhance the service delivery.
• Improving information sharing between agencies.
• The team work to understand the victim and perpetrator experience for those suffering mental ill health through the criminal justice system.
• When referrals are made to the team by an officer or staff, and the person is known by EPUT, the team will share information with them if there is a concern for the person.
• If the person referred is not known or open to EPUT then the referrer will be updated that EPUT do not accept such referrals, but the team will identify other options for consideration. If a person is not known to EPUT but there is a significant risk, officers will be instructed to override GDPR for safeguarding purposes and make a referral to the GP.

• The Essex Police Mental Health Triage team have developed Mental Health Risk Management Briefings (MHRMB) which can be requested by police or partners. The aim of this meeting is to bring all agencies involved with the subject together, or introduce agencies into the process, that need to have some involvement to manage the risk that the subject poses to themselves or the wider public.
• If the MHRMT are requesting a risk management meeting, then the same process is followed other than the MHRMT will contact EPUT with our concerns and ask them to clarify who the interested parties are and call a board. These measures demonstrate Essex Police’s commitment to learn from the risks HM Coroner identified following this tragic death, and to prevent future deaths through a culture of continuous improvement. We welcome the opportunity to strengthen our service. If further detail is required on any of the actions above, I will respond at your direction.