Katrina Makunova
PFD Report
All Responded
Ref: 2021-0388
Community health care and emergency services related deaths
Other related deaths
Police related deaths
All 1 response received
· Deadline: 31 Dec 2021
Coroner's Concerns (AI summary)
Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.
View full coroner's concerns
Concern 1: Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Posession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm he might do led her not to make a full disclosure of his controlling behaviour to the police.
THE CORONER’S SECOND MATTER OF CONCERN
Concern 2: The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely.
THE CORONER’S SECOND MATTER OF CONCERN
Concern 2: The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely.
Responses
Action Planned
The MPS will share the report with relevant departments and review training programmes to include expert evidence-based advice on knife carrying and gang membership in domestic abuse risk assessments. A review of CSU resourcing is underway, with findings to be presented to the MPS Management Board in January 2022. (AI summary)
The MPS will share the report with relevant departments and review training programmes to include expert evidence-based advice on knife carrying and gang membership in domestic abuse risk assessments. A review of CSU resourcing is underway, with findings to be presented to the MPS Management Board in January 2022. (AI summary)
View full response
Dear Mr Harris
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the Metropolitan Police Service (MPS) and I am responding on behalf of the Commissioner of Police of the Metropolis to your Regulation 28 Report to Prevent Future Deaths, dated 18th November 2021. Your report was sent following the conclusion of the inquest into the death of Miss Katrina Makunova who sadly died on 12th July 2018.
The MPS has acknowledged and reviewed all matters of concern raised in your Regulation 28 Report to Prevent Future Deaths and respond as follows:
Matter of Concern 1
University academics are asked to provide expert evidence-based advice about whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse, in the context of cultures where these are prevalent. The MPS is asked to consider how they might use this expert knowledge in preventing future deaths.
The MPS acknowledges the request made by the Senior Coroner to
and for them to provide expert evidence-based advice on whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse.
The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions. The MPS is committed to tackling domestic abuse and violence against women and girls, and on 4th November 2021, the Commissioner launched the new Violence against Women and Girls strategy which aims to improve processes and victim care across the criminal justice system to improve outcomes; reduce the likelihood of women and girls becoming repeat victims; increase women’s confidence in the police and, in doing so, improve the reporting of crimes. The aim is to see an increase in reporting to police, but a decrease in prevalence.
As part of our commitment to continue learning both in the context of domestic abuse and gang violence, Katrina’s death and the sad circumstances surrounding it is now being used as a case study as part of the training delivered to staff in Public Protection.
Matter of Concern 2
The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely.
The Mayor’s Office and MPS are asked to consider whether staffing of CSUs needs to be increased to enable proper risk assessment and safeguarding.
The Deputy Assistant Commissioner for Local Policing requested a broad review of Public Protection within the Metropolitan Police Service (MPS), which is linked to the MPS’s drive to improve outcomes for victims. The work has revealed a significant increase in demand, particularly in relation to reports of Domestic Abuse.
Investigators have seen workloads rise due to an increase in demand and new or changed legislation meaning that investigators are now using Domestic Violence Protection Orders/Notices to a greater extent as well as complying with Clare’s Law, Sarah’s Law and family law disclosures. This extra demand was unaccounted for in the original resource mapping in 2016/2017 for the 12 BCU model that included CSU (Community Safety Unit) officer provision.
It should be noted that the issue is not solely down to numbers of officers in this area and that as part of the review, efficiency and effectiveness in our systems to manage demand and productivity are being explored.
The review is considering a number of options that could be initiated in a relatively short period of time to address some key findings across the MPS. These include a drive to fill current vacancies and review different ways of working aimed at reducing workloads on CSU investigators, their line management and an increase in staffing numbers. In January 2022, the findings from the review will be presented to the MPS Management Board comprising of the Commissioner, Deputy Commissioner and Assistant Commissioners. The final decision as to whether any of the options provided can be pursued, will be made by the Management Board.
In Conclusion
I wish to express my sincere condolences to the family of Miss Makunova. The MPS is committed to promoting a culture of learning and continuous improvement wherever possible.
I trust this provides the reassurance that the MPS has considered the matter of concerns you have raised. Please do not hesitate in contacting me should you have any queries.
I am the Deputy Assistant Commissioner for the Directorate of Professionalism in the Metropolitan Police Service (MPS) and I am responding on behalf of the Commissioner of Police of the Metropolis to your Regulation 28 Report to Prevent Future Deaths, dated 18th November 2021. Your report was sent following the conclusion of the inquest into the death of Miss Katrina Makunova who sadly died on 12th July 2018.
The MPS has acknowledged and reviewed all matters of concern raised in your Regulation 28 Report to Prevent Future Deaths and respond as follows:
Matter of Concern 1
University academics are asked to provide expert evidence-based advice about whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse, in the context of cultures where these are prevalent. The MPS is asked to consider how they might use this expert knowledge in preventing future deaths.
The MPS acknowledges the request made by the Senior Coroner to
and for them to provide expert evidence-based advice on whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse.
The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions. The MPS is committed to tackling domestic abuse and violence against women and girls, and on 4th November 2021, the Commissioner launched the new Violence against Women and Girls strategy which aims to improve processes and victim care across the criminal justice system to improve outcomes; reduce the likelihood of women and girls becoming repeat victims; increase women’s confidence in the police and, in doing so, improve the reporting of crimes. The aim is to see an increase in reporting to police, but a decrease in prevalence.
As part of our commitment to continue learning both in the context of domestic abuse and gang violence, Katrina’s death and the sad circumstances surrounding it is now being used as a case study as part of the training delivered to staff in Public Protection.
Matter of Concern 2
The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely.
The Mayor’s Office and MPS are asked to consider whether staffing of CSUs needs to be increased to enable proper risk assessment and safeguarding.
The Deputy Assistant Commissioner for Local Policing requested a broad review of Public Protection within the Metropolitan Police Service (MPS), which is linked to the MPS’s drive to improve outcomes for victims. The work has revealed a significant increase in demand, particularly in relation to reports of Domestic Abuse.
Investigators have seen workloads rise due to an increase in demand and new or changed legislation meaning that investigators are now using Domestic Violence Protection Orders/Notices to a greater extent as well as complying with Clare’s Law, Sarah’s Law and family law disclosures. This extra demand was unaccounted for in the original resource mapping in 2016/2017 for the 12 BCU model that included CSU (Community Safety Unit) officer provision.
It should be noted that the issue is not solely down to numbers of officers in this area and that as part of the review, efficiency and effectiveness in our systems to manage demand and productivity are being explored.
The review is considering a number of options that could be initiated in a relatively short period of time to address some key findings across the MPS. These include a drive to fill current vacancies and review different ways of working aimed at reducing workloads on CSU investigators, their line management and an increase in staffing numbers. In January 2022, the findings from the review will be presented to the MPS Management Board comprising of the Commissioner, Deputy Commissioner and Assistant Commissioners. The final decision as to whether any of the options provided can be pursued, will be made by the Management Board.
In Conclusion
I wish to express my sincere condolences to the family of Miss Makunova. The MPS is committed to promoting a culture of learning and continuous improvement wherever possible.
I trust this provides the reassurance that the MPS has considered the matter of concerns you have raised. Please do not hesitate in contacting me should you have any queries.
Sent To
Response Status
Linked responses
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56-Day Deadline
31 Dec 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 20th July 2018, I opened an inquest into the death of Katrina Makunova, who died on 12th July 2018 at in (CIO). The inquest was concluded on 8th September 2021. She died of a stab wound and was Unlawfully Killed.
Circumstances of the Death
The relevant circumstances extracted from the long narrative returned by the jury are these: Katrina had suffered a pattern of abuse and coercion and controlling behaviour herself and seen a pattern of violence and threats against her family members and friends. This included her boy friend carrying and displaying his knife in situations he was controlling. This left her feeling isolated, scared, and depressed. This culminated in her carrying a knife when she went to see the perpetrator on 12 th July 2018, upon which she fatally fell when pushed by her ex boy friend. Re the transfer of responsibilities, between local authorities in 2016: Katrina was vulnerable because of her past trauma, experiences, and age. This vulnerability increased her risk of contextual harm. It also made engaging with authorities more difficult. LB Bromley and the Metropolitan Police Service were unaware of her vulnerability because they didn’t attend the Merton Child Protection Conference. Between February 2018 and her death in July 2018, there were five incidents between Katrina and the perpetrator at which her vulnerability wasn’t accounted for when organizations made their risk assessments.
Incident 1 on 6th February 2018 the significance of the theft of the phone which led to the perpetrator controlling her communications, was not recognized. (Knife carrying was not recorded on the 124D) Incident 2: On 13th February 2018 police were called to Katrina’s work address. At the scene, she described, and the police identified, clear examples of coercion and controlling behaviour, but when the suspect was released from custody, police didn’t take any mitigating safeguarding actions. (Knife carrying history was not recorded or questioned). Incident 3: On 11th July 2018 police were called to her home. The following were admitted failures of MPS officers: A failure to assess and manage risk, A failure to investigate the allegations of victim of domestic abuse, A failure to provide effective safeguarding as no Merlin report was sent Incident 4: On 23rd June 2018 police were called to her home. The following were admitted failures of MPS officers: A failure to acknowledge that there was a report of criminal allegations of harassment and record incident as a crime; A failure to properly assess and manage and record risk as no booklet 124 D was completed and misleading information was entered on the crime report and A failure to safeguard a child as no Merlin report was sent Incident 5: On 27th June 2018 Katrina and the perpetrator attended Walworth Police Station following a dispute. High case loads contributed to the delay in implementing CSU supervisor directions. This incident wasn’t considered urgent, because it was viewed as an isolated incident. The following were admitted failures of MPS officers: A failure to conduct proper and diligent intelligence checks, A failure to investigate allegation of domestic abuse and A failure to provide adequate safeguarding as no Merlin form was sent.
Incident 1 on 6th February 2018 the significance of the theft of the phone which led to the perpetrator controlling her communications, was not recognized. (Knife carrying was not recorded on the 124D) Incident 2: On 13th February 2018 police were called to Katrina’s work address. At the scene, she described, and the police identified, clear examples of coercion and controlling behaviour, but when the suspect was released from custody, police didn’t take any mitigating safeguarding actions. (Knife carrying history was not recorded or questioned). Incident 3: On 11th July 2018 police were called to her home. The following were admitted failures of MPS officers: A failure to assess and manage risk, A failure to investigate the allegations of victim of domestic abuse, A failure to provide effective safeguarding as no Merlin report was sent Incident 4: On 23rd June 2018 police were called to her home. The following were admitted failures of MPS officers: A failure to acknowledge that there was a report of criminal allegations of harassment and record incident as a crime; A failure to properly assess and manage and record risk as no booklet 124 D was completed and misleading information was entered on the crime report and A failure to safeguard a child as no Merlin report was sent Incident 5: On 27th June 2018 Katrina and the perpetrator attended Walworth Police Station following a dispute. High case loads contributed to the delay in implementing CSU supervisor directions. This incident wasn’t considered urgent, because it was viewed as an isolated incident. The following were admitted failures of MPS officers: A failure to conduct proper and diligent intelligence checks, A failure to investigate allegation of domestic abuse and A failure to provide adequate safeguarding as no Merlin form was sent.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and the organizations to which this report is addressed are asked:
Re concern 1. University academics are asked to provide expert evidence-based advice about whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse, in the context of cultures where these are prevalent. The MPS is asked to consider how they might use this expert knowledge in preventing future deaths.
Re concern 2. The Mayor’s Office and MPS are asked to consider whether staffing of CSUs needs to be increased to enable proper risk assessment and safeguarding.
Re concern 1. University academics are asked to provide expert evidence-based advice about whether and how knife carrying and gang membership should be considered in assessment of risk to sufferers of domestic abuse, in the context of cultures where these are prevalent. The MPS is asked to consider how they might use this expert knowledge in preventing future deaths.
Re concern 2. The Mayor’s Office and MPS are asked to consider whether staffing of CSUs needs to be increased to enable proper risk assessment and safeguarding.
Copies Sent To
5th November 2021 Andrew Harris, Senior Coroner
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.