Nicola Forster
PFD Report
All Responded
Ref: 2024-0334
All 1 response received
· Deadline: 15 Aug 2024
Coroner's Concerns (AI summary)
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing speaking out and senior management failing to address concerns independently.
View full coroner's concerns
Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki's death, including the introduction of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists. My investiation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
Responses
Action Taken
The Metropolitan Police Service has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. (AI summary)
The Metropolitan Police Service has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. (AI summary)
View full response
Dear Mrs Whitting,
I am the Deputy Assistant Commissioner for Professionalism 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 20 June 2024.
On behalf of the MPS, may I first express my sincere condolences to the family and friends of Nicola Forster; our thoughts and sympathies are very much with them.
On 23 May 2024, the MPS wrote to address you on a number of matters. 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”
“Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki’s death, including the introduction of a new ‘Raising Concerns’ Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists.
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by
Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
MPS Response
The Commissioner has been clear since his appointment of his expectations and the need for the MPS to not be defensive. An approach that the Commissioner, Management Board and the wider MPS seeks to reflect through our principles about how we make our decisions, and our values about how we behave. The New Met for London plan sets out that the Commissioner and the MPS want to build a culture in the MPS which is open, honest and works closely with external organisations and the public to deliver our services with communities.
Under the Commissioner, we have refreshed and introduced new values and operating principles, which we continue to embed across the organisation. We seek to put communities first, be frontline focused, inclusive, collaborative and precise; and being accountable is one of our core values.
We are doing more to learn from external partners, other police forces, reviews and inspections. For example, last year the Commissioner and the senior team led a series of 32 borough events, which saw the MPS senior management team out in every London Borough to talk about the issues affecting them and the New Met for London plan.
As set out in the letter from the MPS dated 23 May 2024, the MPS introduced a new “Raising Concerns” policy regarding the reporting of wrongdoing within the MPS. The new policy, introduced in May 2023, is directly focussed on supporting officers and staff who may have a concern about a colleague. Changes include:-
• An expanded scope of the previous whistleblowing policy, to include anyone who raises any concern to anyone within the organisation,
• Improved guidance on how to report different concerns,
• The provision of clearer responsibilities for line managers in relation to the actions they must take whenever a concern is reported to them, and
• Sets out MPS expectations that everyone who raises a concern, in good faith, will be listened to and supported.
One of the main aims is that where an officer has a concern similar to those which were being expressed by PS Forster to her friends and family, or where her colleagues have such concerns, they can be confident they will be listened to and supported.
Whilst staff are encouraged and supported to report concerns openly in person, there are a number of ways a report can be made, including via anonymised telephone and online reporting. To ensure individuals have the flexibility to choose the most appropriate method of reporting for them. In November 2022, the MPS was the
first force in the UK to launch a public facing reporting service for complaints and conduct, in partnership with Crimestoppers. By March 2024, the hotline has received nearly 3,000 reports; leading to over 700 investigations.
The MPS recognises that changes to policy and practice alone, will not change culture within the MPS. The MPS has a dedicated Assistant Commissioner and Deputy Assistant Commissioner for Trust and Legitimacy, and established a Culture programme as part of the New Met for London commitments, focused on driving the culture changes we recognise are needed across the organisation. The Culture programme seeks to build staff confidence to speak up and raise concerns, and for managers and leaders to listen and respond. Activity includes:
• The development of the new MPS values and their use in our people focused policies and processes; such as recruitment, performance management and promotions.
• The launch of the Upstander programme: designed to improve the confidence and capability of staff to challenge behaviours that are inappropriate and not aligned with our values. The Upstander programme is also designed to increase the understanding and capabilities of leaders to support staff and resolve issues.
The Culture programme is a critical delivery priority for the MPS. It is supported by the creation of a new directorate to drive transformation and improvements in response to the findings of external reviews and inspections of the MPS, and our commitments within the New Met for London strategy.
Effective leadership and helping employees perform to the best of their abilities is a central role of line managers. Employees need to understand what is expected of them and be effectively led and managed, so that they are motivated, have the skills, resources and support that they need to succeed and be accountable for their work. As you are aware policing is a complex and demanding environment where the public rightly expect effective policing and high standards. We ask our line managers to do very difficult roles to lead and properly manage the performance of their staff, alongside what can be complex individual welfare needs - all set against the demands of delivering policing for London.
In this case, the actions of the individual line manager were investigated and we are satisfied that she worked hard to find the right balance of performance management and welfare support in this case. The MPS is of the view that the learning here is at an organisational level, rather than for the individual. The MPS accepts that there should have been better supporting infrastructure in place to support Nicola and her line manager. This is something that we continuously review. We continue to undertake significant work to improve both our performance management processes (a two way process between the line manager and the individual), and how we develop the skills of managers and others to support colleagues who are going through professional and / or personal challenges, as outlined in our post inquest written submission to you.
In April 2023, the MPS introduced new leadership training for all first line leaders. This is mandatory and equates to between 3 and 8 days of training depending on the role being performed. A dedicated module focused upon trauma and wellbeing is included within this new leadership programme. Between April 2023 and April 2024, c6200 leaders across the MPS have completed this training. Based on a 98% course feedback response rate, 93% said they found the course valuable and would recommend to colleagues. Informal weekly feedback from course facilitators consistently highlighted trauma and wellbeing as a priority theme that delegates found valuable.
Year 2 of the First Line Leaders’ leadership programme launched in April 2024. Responding to staff feedback, there is an updated focus on trauma and wellbeing with scenario and discussion based learning. Sessions have clear learning outcomes, including role modelling behaviours that foster wellbeing, and signposting access to wellbeing support and referral mechanisms. Delegates can arrange for additional Trauma Impact Prevention Techniques Training for their teams; a preventative technique designed by Police Care UK in conjunction with Cambridge University that has been developed specifically for (and with) the Police, given the high levels of trauma exposure for police officers. From March 2024, new leadership training programmes have also commenced for senior leaders, which includes content on trauma and wellbeing.
The MPS is also investing in new People & Performance Improvement Teams for every front line command unit, embedding HR expertise locally to assist line managers with more complex HR issues. This will ensure the appropriate support is in place for our employees and their line managers. We have rolled out ten of 18 PPIT teams from January 2024, with the further eight team recruitment in progress and expected to be in place between August and October 2024. Whilst early stages, we are already seeing an impact for local leaders and line managers.
Alongside broader cultural reforms across the MPS set out in a New Met for London, specific changes have been implemented within Learning and Development (“L&D”) over the past 12 months. These have focused on creating a positive and supportive culture for all colleagues working within L&D. Significantly, this has included a number of changes to the L&D Senior Leadership Team, bringing in experience of delivering cultural reform from elsewhere in the MPS and outside of the policing, strengthened supervision and greater levels of oversight with regards to supporting the wellbeing of colleagues across L&D.
Investment in a new L&D People Strategy in 2023 was in direct response to staff feedback from the 2022 staff survey and aims to makes a positive difference for those working in L&D, as well as fostering a culture of trust. Significant improvements include a more structured, co-ordinated and comprehensive programme of wellbeing and welfare support for L&D staff; recognition for those staff who go ‘above and beyond’ in embodying the MPS’s guiding principles and values; visible Senior Leadership Team engagement across all teams and locations; and an increased focus in identifying common themes with regards to professional standards and culture which are overseen by the Director L&D.
Looking ahead, L&D are in the process of creating a new strategy and performance function. To inform this work senior leaders are actively seeking colleagues’ inputs and suggestions on what more leaders can do to better support colleagues.
As part of our reform of the MPS, to identify and respond to individual and organisational learning, we have invested resources and are transforming our approach to ensure high standards. The MPS Directorate of Professional Standards (DPS) investigation that followed Nicola Forster’s death commenced when information was received from a former police officer that Nicola had been bullied. In accordance with the regulatory framework, the conduct allegation was recorded and investigated by the DPS Discrimination Investigation Unit, which specialises in matters of discrimination and bullying. The requirements and purpose of such a conduct investigation are set out within regulations and statutory guidance.
The investigation was independent of L&D, and did not seek to support the leaders within L&D. In accordance with the statutory regulations, once the investigation was completed, it was considered by an independent Appropriate Authority, who reviewed the evidence and concluded that the line manager had no case to answer for misconduct, as defined in the Police (Conduct) Regulations.
Whilst there was no finding of conduct, the DPS investigation did identify that improvements should be made to the way line managers transferred staff when changing roles, and for leaders to have appropriate access to officer/staff personal circumstances in order that they have the information necessary to support individuals. I understand evidence was read at inquest which provided detail of a new functionality within the MPS performance and development system that enables new line managers to have a greater awareness of an individual’s history.
At inquest, the Commissioner was represented by the Directorate of Legal Services (“DLS”). Nicola Forster’s line manager was separately legally represented as she was given Interested Person status at inquest. All police witnesses, except one individual, who gave evidence at inquest were supported by the MPS. You will be aware that some witnesses gave frank and often critical evidence about the MPS, this did not change the support they were provided.
Current and former police officers and staff called as witnesses to an inquest, where the Commissioner is an Interested Party, are provided with support. This includes:
• Provision of relevant documents;
• Assistance with the preparation of any statement;
• A point of contact for officer/staff to ask any questions they have about the inquest process;
• Case conference with DLS and MPS counsel, to assist the witness’s understanding the nature of an inquest, their role as witnesses and to assist them with any questions they have.
At all times, it is made clear to officers and staff that they are the Coroner’s witness, not the Commissioner’s witness, and their evidence is their own. The MPS also has a dedicated team within its Inquiry & Review Support Command (IRSC), who provide operational and practical support to police officers and staff who give evidence at inquests, where the Commissioner is an interested party. This inquest team provide a single point of contact for witnesses, both prior to and during inquest proceedings.
The IRSC also work closely with DLS to review inquest outcomes for both case specific learning and to identify themes that arise through analysis of different inquest proceeding. The MPS has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. This is improving how the MPS seeks to learn and ensure that any identified improvements are shared through wider organisational learning, for example changes to leadership training and wellbeing support.
The Commissioner and the MPS are committed to making the improvements we recognise are needed in our culture to become less defensive, as reflected through our principles about how we make our decisions, and our values about how we behave. I hope this response provides you with an appropriate level of assurance in relation to that commitment.
Please do not hesitate to contact me should you require any additional information or clarification regarding the above.
I am the Deputy Assistant Commissioner for Professionalism 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 20 June 2024.
On behalf of the MPS, may I first express my sincere condolences to the family and friends of Nicola Forster; our thoughts and sympathies are very much with them.
On 23 May 2024, the MPS wrote to address you on a number of matters. 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”
“Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki’s death, including the introduction of a new ‘Raising Concerns’ Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists.
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by
Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
MPS Response
The Commissioner has been clear since his appointment of his expectations and the need for the MPS to not be defensive. An approach that the Commissioner, Management Board and the wider MPS seeks to reflect through our principles about how we make our decisions, and our values about how we behave. The New Met for London plan sets out that the Commissioner and the MPS want to build a culture in the MPS which is open, honest and works closely with external organisations and the public to deliver our services with communities.
Under the Commissioner, we have refreshed and introduced new values and operating principles, which we continue to embed across the organisation. We seek to put communities first, be frontline focused, inclusive, collaborative and precise; and being accountable is one of our core values.
We are doing more to learn from external partners, other police forces, reviews and inspections. For example, last year the Commissioner and the senior team led a series of 32 borough events, which saw the MPS senior management team out in every London Borough to talk about the issues affecting them and the New Met for London plan.
As set out in the letter from the MPS dated 23 May 2024, the MPS introduced a new “Raising Concerns” policy regarding the reporting of wrongdoing within the MPS. The new policy, introduced in May 2023, is directly focussed on supporting officers and staff who may have a concern about a colleague. Changes include:-
• An expanded scope of the previous whistleblowing policy, to include anyone who raises any concern to anyone within the organisation,
• Improved guidance on how to report different concerns,
• The provision of clearer responsibilities for line managers in relation to the actions they must take whenever a concern is reported to them, and
• Sets out MPS expectations that everyone who raises a concern, in good faith, will be listened to and supported.
One of the main aims is that where an officer has a concern similar to those which were being expressed by PS Forster to her friends and family, or where her colleagues have such concerns, they can be confident they will be listened to and supported.
Whilst staff are encouraged and supported to report concerns openly in person, there are a number of ways a report can be made, including via anonymised telephone and online reporting. To ensure individuals have the flexibility to choose the most appropriate method of reporting for them. In November 2022, the MPS was the
first force in the UK to launch a public facing reporting service for complaints and conduct, in partnership with Crimestoppers. By March 2024, the hotline has received nearly 3,000 reports; leading to over 700 investigations.
The MPS recognises that changes to policy and practice alone, will not change culture within the MPS. The MPS has a dedicated Assistant Commissioner and Deputy Assistant Commissioner for Trust and Legitimacy, and established a Culture programme as part of the New Met for London commitments, focused on driving the culture changes we recognise are needed across the organisation. The Culture programme seeks to build staff confidence to speak up and raise concerns, and for managers and leaders to listen and respond. Activity includes:
• The development of the new MPS values and their use in our people focused policies and processes; such as recruitment, performance management and promotions.
• The launch of the Upstander programme: designed to improve the confidence and capability of staff to challenge behaviours that are inappropriate and not aligned with our values. The Upstander programme is also designed to increase the understanding and capabilities of leaders to support staff and resolve issues.
The Culture programme is a critical delivery priority for the MPS. It is supported by the creation of a new directorate to drive transformation and improvements in response to the findings of external reviews and inspections of the MPS, and our commitments within the New Met for London strategy.
Effective leadership and helping employees perform to the best of their abilities is a central role of line managers. Employees need to understand what is expected of them and be effectively led and managed, so that they are motivated, have the skills, resources and support that they need to succeed and be accountable for their work. As you are aware policing is a complex and demanding environment where the public rightly expect effective policing and high standards. We ask our line managers to do very difficult roles to lead and properly manage the performance of their staff, alongside what can be complex individual welfare needs - all set against the demands of delivering policing for London.
In this case, the actions of the individual line manager were investigated and we are satisfied that she worked hard to find the right balance of performance management and welfare support in this case. The MPS is of the view that the learning here is at an organisational level, rather than for the individual. The MPS accepts that there should have been better supporting infrastructure in place to support Nicola and her line manager. This is something that we continuously review. We continue to undertake significant work to improve both our performance management processes (a two way process between the line manager and the individual), and how we develop the skills of managers and others to support colleagues who are going through professional and / or personal challenges, as outlined in our post inquest written submission to you.
In April 2023, the MPS introduced new leadership training for all first line leaders. This is mandatory and equates to between 3 and 8 days of training depending on the role being performed. A dedicated module focused upon trauma and wellbeing is included within this new leadership programme. Between April 2023 and April 2024, c6200 leaders across the MPS have completed this training. Based on a 98% course feedback response rate, 93% said they found the course valuable and would recommend to colleagues. Informal weekly feedback from course facilitators consistently highlighted trauma and wellbeing as a priority theme that delegates found valuable.
Year 2 of the First Line Leaders’ leadership programme launched in April 2024. Responding to staff feedback, there is an updated focus on trauma and wellbeing with scenario and discussion based learning. Sessions have clear learning outcomes, including role modelling behaviours that foster wellbeing, and signposting access to wellbeing support and referral mechanisms. Delegates can arrange for additional Trauma Impact Prevention Techniques Training for their teams; a preventative technique designed by Police Care UK in conjunction with Cambridge University that has been developed specifically for (and with) the Police, given the high levels of trauma exposure for police officers. From March 2024, new leadership training programmes have also commenced for senior leaders, which includes content on trauma and wellbeing.
The MPS is also investing in new People & Performance Improvement Teams for every front line command unit, embedding HR expertise locally to assist line managers with more complex HR issues. This will ensure the appropriate support is in place for our employees and their line managers. We have rolled out ten of 18 PPIT teams from January 2024, with the further eight team recruitment in progress and expected to be in place between August and October 2024. Whilst early stages, we are already seeing an impact for local leaders and line managers.
Alongside broader cultural reforms across the MPS set out in a New Met for London, specific changes have been implemented within Learning and Development (“L&D”) over the past 12 months. These have focused on creating a positive and supportive culture for all colleagues working within L&D. Significantly, this has included a number of changes to the L&D Senior Leadership Team, bringing in experience of delivering cultural reform from elsewhere in the MPS and outside of the policing, strengthened supervision and greater levels of oversight with regards to supporting the wellbeing of colleagues across L&D.
Investment in a new L&D People Strategy in 2023 was in direct response to staff feedback from the 2022 staff survey and aims to makes a positive difference for those working in L&D, as well as fostering a culture of trust. Significant improvements include a more structured, co-ordinated and comprehensive programme of wellbeing and welfare support for L&D staff; recognition for those staff who go ‘above and beyond’ in embodying the MPS’s guiding principles and values; visible Senior Leadership Team engagement across all teams and locations; and an increased focus in identifying common themes with regards to professional standards and culture which are overseen by the Director L&D.
Looking ahead, L&D are in the process of creating a new strategy and performance function. To inform this work senior leaders are actively seeking colleagues’ inputs and suggestions on what more leaders can do to better support colleagues.
As part of our reform of the MPS, to identify and respond to individual and organisational learning, we have invested resources and are transforming our approach to ensure high standards. The MPS Directorate of Professional Standards (DPS) investigation that followed Nicola Forster’s death commenced when information was received from a former police officer that Nicola had been bullied. In accordance with the regulatory framework, the conduct allegation was recorded and investigated by the DPS Discrimination Investigation Unit, which specialises in matters of discrimination and bullying. The requirements and purpose of such a conduct investigation are set out within regulations and statutory guidance.
The investigation was independent of L&D, and did not seek to support the leaders within L&D. In accordance with the statutory regulations, once the investigation was completed, it was considered by an independent Appropriate Authority, who reviewed the evidence and concluded that the line manager had no case to answer for misconduct, as defined in the Police (Conduct) Regulations.
Whilst there was no finding of conduct, the DPS investigation did identify that improvements should be made to the way line managers transferred staff when changing roles, and for leaders to have appropriate access to officer/staff personal circumstances in order that they have the information necessary to support individuals. I understand evidence was read at inquest which provided detail of a new functionality within the MPS performance and development system that enables new line managers to have a greater awareness of an individual’s history.
At inquest, the Commissioner was represented by the Directorate of Legal Services (“DLS”). Nicola Forster’s line manager was separately legally represented as she was given Interested Person status at inquest. All police witnesses, except one individual, who gave evidence at inquest were supported by the MPS. You will be aware that some witnesses gave frank and often critical evidence about the MPS, this did not change the support they were provided.
Current and former police officers and staff called as witnesses to an inquest, where the Commissioner is an Interested Party, are provided with support. This includes:
• Provision of relevant documents;
• Assistance with the preparation of any statement;
• A point of contact for officer/staff to ask any questions they have about the inquest process;
• Case conference with DLS and MPS counsel, to assist the witness’s understanding the nature of an inquest, their role as witnesses and to assist them with any questions they have.
At all times, it is made clear to officers and staff that they are the Coroner’s witness, not the Commissioner’s witness, and their evidence is their own. The MPS also has a dedicated team within its Inquiry & Review Support Command (IRSC), who provide operational and practical support to police officers and staff who give evidence at inquests, where the Commissioner is an interested party. This inquest team provide a single point of contact for witnesses, both prior to and during inquest proceedings.
The IRSC also work closely with DLS to review inquest outcomes for both case specific learning and to identify themes that arise through analysis of different inquest proceeding. The MPS has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. This is improving how the MPS seeks to learn and ensure that any identified improvements are shared through wider organisational learning, for example changes to leadership training and wellbeing support.
The Commissioner and the MPS are committed to making the improvements we recognise are needed in our culture to become less defensive, as reflected through our principles about how we make our decisions, and our values about how we behave. I hope this response provides you with an appropriate level of assurance in relation to that commitment.
Please do not hesitate to contact me should you require any additional information or clarification regarding the above.
Sent To
- Metropolitan Police Service
Response Status
Linked responses
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56-Day Deadline
15 Aug 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 12 October 2022 I commenced an investigation into the death of Nicola FORSTER aged 45. The investigation concluded at the end of the Inquest on 03 June 2024. The Conclusion of the Inquest was that: The Deceased intentionally took her own life following a deterioration in her mental health which was exacerbated by the actions of her employer.
Circumstances of the Death
The Deceased, a serving Metropolitan Police Service (MPS) Sergeant, had worked for the MPS for over twenty-two and a half years mostly as a front-line officer; in early 2020, she had joined the Learning and Development Team at Hendon as a Public & Personal Safety Instructor Sergeant, which was a job she loved. She had struggled with mental and physical health issues for several years, including work-related PTSD, but had found counselling helpful for dealing with this. Her mental health declined from autumn 2021 when she found herself under increasing pressure at work and lost access to counselling. An Occupational Health Referral was discussed with her line manager but was not progressed until 23 May 2022 when, because her health had impacted on her ability to lead and supervise her Team, she was also issued with informal management action. Although she was always open about her mental health issues, line management decisions made in respect of her reflected a focus on managing upwards and were supported by the Senior Leadership Team; these decisions were at the expense of the Deceased’s personal and occupational welfare and contributed to a further significant deterioration in her mental health. Despite the intervention of the Deceased’s local mental health Crisis Team, who provided her with out-patient care from 21 September 2022, on the morning of 28 September 2022, she was found hanging by a ligature made from her dressing gown belt attached to the landing banisters at her home. Emergency Services attended but her death was confirmed by paramedics at 10.56 hours. She had last been heard from at around 01.00 hours that morning when she had sent a text message to her partner saying that her sleeping medication was not working.
Copies Sent To
(Associate Legal Director ELFT) Mayor of London
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