Dear Mr Irvine,

On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths dated 29th September 2025 following the inquest into the tragic death of Mr Jake Hickey Girton.

On behalf of the MPS, may I first express my sincere condolences to the family and friends of Mr Girton, 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” and the MPS’ Responses

Matter of Concern 1

Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake's release from custody. There is no evidence to suggest this was done. Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, they were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community.

MPS Response

The relevant policy and guidance that applies here are the Victims’ Code and the MPS General Investigations Policy (GI).

The Victims’ Code defines a victim as below:

“Who is a ‘victim’ under this Code? This Code acknowledges that the terms ‘complainant’ and ‘survivor’ are often used in the criminal justice system to describe a person who has made a criminal allegation to the police. However, for the purpose of this Code, the definition of a ‘victim’ is:
• a person who has suffered harm, including physical, mental or emotional harm or economic loss which was directly caused by a criminal offence.
• a close relative (or a nominated family spokesperson) of a person whose death was directly caused by a criminal offence.

You can also receive Rights under this Code if you are:
• a parent or guardian of the victim if the victim is under 18 years of age or
• a nominated family spokesperson if the victim has a mental impairment or has been so badly injured because of a criminal offence that they are unable to communicate or lacks the capacity to do so.

The Victims’ Code in this incident applies to the member of staff at Goodmayes Hospital who was the alleged victim of assault by Mr Girton. The officer in the case (OIC) informed the victim of Mr Girton’s release from custody and VCOP was accordingly complied with.

Businesses/charities can be victims of crime but the Victims Code is specifically for people rather than organisations or institutions.

The GI provides guidance and actions for all criminal investigations and stipulates actions to be taken with regards to victims of crime. The GI Policy is the relevant policy for the hospital. The policy in place at the time of death stated:

‘3.4 Victims and witnesses – actions that must be taken involving victims and witnesses

Every officer MUST follow the requirements set out in the VCOP policy whilst completing the actions set out below […]
3.4.1 Obtain victim/witness full contact details including their preferred method of contact, alternative phone numbers, email addresses […]
3.4.9 All contact and attempted contact with the victim should be recorded on the CRIS investigation as well as any investigative actions that arise from these communications.
3.4.10 Provide the victim with a Victim Care Card and explain what will happen next even if no further action is to be taken.’

The GI Policy states VCOP should be adhered to as well as the outlined actions, highlighting them as distinctly different and applicable in addition. The OIC did not separately inform Goodmayes Hospital of Mr Girton’s release from custody in respect of the hospital’s status as a victim from the offence of criminal damage. The OIC did however inform the same member of staff who was the alleged victim of assault. This victim’s details were present on the CRIS report for the criminal damage. The OIC has confirmed that he held a genuine expectation that the victim would duly update the hospital records.

The MPS are currently reviewing the GI policy and propose to include the following section to ensure there is clarity around the responsibility to provide updates to representatives of businesses and other enterprises:

‘Businesses or other enterprises such as charities are not included within the definition of a victim under the Victims’ Code. However, they can be victims of crime and receive the services in the Code and make an impact statement where a criminal offence has been committed against them, subject to provision of a named point of contact to the relevant service provider. For the purposes of this policy, and in recognition of the need for effective communication during investigations, officers should identify and liaise with the most appropriate named point of contact within affected businesses/organisations to provide relevant updates. Where a crime is perpetrated against both an individual (e.g. an employee) and the organisation they represent, officers must ensure that investigative updates are provided separately to the individual victim in accordance with the Victims' Code, and to the organisation via a suitable representative. This ensures that individuals receive appropriate support, distinct from the organisation’s interests and obligations.’

The section above is currently undergoing final approval and is scheduled to be incorporated into the policy in 2026.

The MPS acknowledges the Coroner’s concerns regarding the sharing of information between police and mental health services when individuals experiencing mental health crisis are released from police custody. The MPS recognise the importance of timely and effective communication to ensure appropriate follow up and reduce the risk of harm.

A review has already been undertaken in relation to information sharing with Mental Health Trusts which has identified a gap in current arrangements. Specifically, there is no consistent mechanism to ensure Mental Health services are notified when an individual is released from custody. This gap can result in missed opportunities for early intervention and continuity of care.

To address this, the MPS has initiated the following measures:

1. The MPS has completed mapping of existing information sharing pathways. This work has clarified where current processes fail or rely on ad hoc communication rather than a formulised system.

2. The MPS is developing a protocol, agreed through local partnership governance to ensure that when a person identified as being in mental health crisis or having been arrested in a mental health setting, is released from custody, relevant information can be shared promptly and lawfully with the appropriate Mental Health Trust or Community Mental Health Team, if known. This protocol is being aligned with data protection and safeguarding requirements under existing information governance frameworks.

3. The MPS is working with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to develop consistent arrangements across London. This includes establishing clear lines of accountability and escalation routes where concerns arise about a person’s welfare post release.

4. Additional guidance is being developed for custody and investigating officers, supported by the MPS Mental Health Lead. This will reinforce the importance of identifying those at risk, recording relevant indicators and initiating the appropriate referral or notification before release.

The MPS is committed to strengthening partnership working with health services to prevent future deaths and ensure vulnerable individuals receive the right care and support at the earliest opportunity. The MPS will continue to monitor progress through the JMHPG.

Matter of Concern 2

Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing.

MPS Response

The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury1 (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.

It is noted in the matter of concern that the failure to update the facility was a conduct/performance/learning matter and that this should have been identified by the DPS. The MPS believe the DSI review was appropriate and went as far as would be expected.

1 A DSI matter means any circumstances (unless the circumstances are or have been the subject of a complaint or amount to a conduct matter) in, or as a result of which, a person has died or sustained serious injury and:
• at the time of death or serious injury the person had been arrested by a person serving with the police and had not been released or was otherwise detained in the custody of a person serving with the police; or
• at or before the time of death or serious injury the person had contact of any kind – whether direct or indirect – with a person serving with the police who was acting in the execution of their duties and there is an indication that the contact may have caused – whether directly or indirectly – or contributed to the death or serious injury. However, this sub-category excludes contact that a person who suffered the death or serious injury had whilst they were acting in the execution of their duties as a person serving with the police.

Section 12, Police Reform Act 2002

‘Serious injury’ means a fracture, a deep cut, a deep laceration or an injury causing damage to an internal organ or the impairment of any bodily function.

Section 29, Police Reform Act 2002

Please do not hesitate to contact me should you require further information from the MPS.