Dear Mr Urpeth, Your reference: Req 28 report to prevent future deaths followinq inquest into the death of Miss Emily Greene. Dear Mr Urpeth, I hope this letter finds you in good health. I am writing to you today to provide South Yorkshire Police's response to the Regulation 28 report to prevent future deaths following the inquest into the tragic death of Miss Emily Greene. I enclose our response at Appendix A attached. This report addresses separately, each of the six matters of concern raised. South Yorkshire Police are committed to learning the lessons from this case and I would like to reassure you that we have already taken action in respect of the findings. I also enclose with this letter, the Sexual Offences booklet (CID40) and the document Complete Victim Care (CVC) that are referred to in the report for your attention and assistance. I would also like to invite you to visit one of our 10 Achieving Best Evidence rooms within the Force. As is referred to in the report, although all of these are fit for purpose, there is currently a programme of refurbishment taking place to enhance them.

RESTRICTED Police Headquarters Carbrook House 5 Carbrook Hall Road Sheffield S9 2EH E-mail: chief@southyorks.pnn.police.uk Please do let me know if you require any further information, or alternatively, if you would prefer to seek out the opportunity to discuss these issues further in a face to face meeting. I am of course more than willing to take on board any particular advice or further feedback.

Chief Constable Yours Si c r ly,

1 Matter of Concern 1: There was employment of an officer into a specialist sexual offences unit without the officer being given specialist training before he started work: was the OIC (Officer in the case) in relation to the investigation in which Emily Greene reported historic sexual offences against DC joined South Yorkshire Police in January 2017 having been previously employed by the Metropolitan Police Service between 2007 and 2014. Having been on a career break for less than 3 years he was accepted as a direct transfer, in accordance with our recruitment policies. When Dc—was accepted by South Yorkshire Police, he provided information that he had undertaken a variety of training courses and had attained the level of a PIP 2 accredited Detective. This qualification indicated that DC— as capable and suitable to investigate serious and complex investigations. On reviewing the training records of DC f0110wing can be confirmed: Date Course Pass/ Fail March 2007 Joined Metropolitan Police Pass July 2007 Completion of foundation training Pass April 2009 Investigative Interview of Suspects — Serious and Complex Pass July 2009 Primary Investigative Training — Critical Incident Sexual Offences Pass Dec 2010 Serious and Complex Interview Course Pass April 2011 Crime Investigators Development Programme Pass May 2011 Crime Investigators Development Programme PIP 2 Pass April 2012 PIP 2 Investigator Accreditation approved Pass June 2014 Public Protection — Abusive relationship Pass June 2014 Public Protection — Family disturbance Pass June 2014 Public Protection — Initial response Pass June 2014 Public Protection — Missing Daughter Pass Dec 2016 Email to SYP confirming DC PiP 2 status

Jan 2017 Joins SYP less than 3 yrs out so direct transfer Pass Jan 2017 Completed 7 day Transferee Course Pass March 2017 Human Trafficking And Modern Slavery Training Pass May 2017 Investigator Masterclass Pass May 2017 Specialist Child Abuse Course — SCAIDP Pass We have highlighted for your assistance the parts of the record relevant to his role and the investigation subject to your Inquest. Of note, the PIP2 completion in April 2012 indicates that DC was assessed as capable of undertaking serious and complex investigations, including sexual offences and the status of Detective awarded. On the commencement of service within South Yorkshire Police in January 2017, DC attended a 7-day transferee induction course, covering systems and processes within the organisation.

2 Due to investigative background, he was posted to the Child Protection team at Barnsley, commencing late January 2017. It appears that he worked on a regular basis with another very experienced Detective within the unit. As a consequence of this review the process for transferees has been revisited and there is now an expectation that on moving to their substantive post a local mentor in the same department will be formally appointed to ensure familiarisation with local processes and practice not covered at induction. In May 2017, and contrary to the evidence provided at the inquest by D he attended an Investigators masterclass followed by the nationally accredited Specialist Child Abuse Investigation Development Programme (SCAIDP). This is a national specialist course designed by the College of Policing and is aimed at developing investigators working within the Child Abuse Investigation arena from the both the Police and Social Care. The objectives of the course are to:

Develop an understanding of child development and identify vulnerabilities of child development in the context of abuse, including understanding the paediatrician perspective in terms of non-accidental injury. Develop an understanding of sexual offending behaviour including grooming and apply the knowledge to child abuse investigations.

Develop a sensitive, ethical and anti-discriminatory approach through policing principles in identifying, assessing and responding to complaints of child abuse and evaluate risk factors within the investigation.

Develop an understanding of the multi-agency working approach; the practices, policy, procedures and legislation that binds the working relationship together in Child Abuse Investigations. The second week on SYP also includes refresher Achieving Best Evidence (ABE) victim training. Modules include:

Child development in context of abuse

Understanding sexual offending behaviour

Investigating child abuse

Multi-agency working — in practice

Safeguarding

Attachment & Development

Behaviour & Assessment

Trauma, Facts & Statistics

Offences South Yorkshire Police continue to deliver the national SCAIDP course in partnership with the four local authorities within South Yorkshire. One of the key objectives is to ensure cross over learning with the other agencies and for officers to better understand and be able to contribute to successful partnership working.

3 In conclusion, the above details and his training record since 2007 demonstrate that DC—wasa trained and accredited detective from his time in the MPS. On arrival in South Yorkshire Police, he worked alongside an experienced public protection DC before passing the national SCAIDP course four months later. D has received extensive training in relation to the investigation of sexual offences involving child victims and was suitably qualified and experienced to undertake the investigation involving Miss Greene. South Yorkshire Police does however recognise the importance of doing its very best to equip public protection officers and we are therefore developing a bespoke course for staff to attend when they are first posted to work within the department. This course will give additional training around areas including Child Abuse, Sudden Unexpected Death of a Child or Infant, Child Sexual Exploitation, Neglect, Multi Agency working and victim care and referral services. The course will work in partnership with the nationally recognised SCAIDP course to ensure staff have a wide knowledge base of both local and national processes. This course is currently being developed by subject matter experts from across the force, it is anticipated this course will be delivered from April 2021 onwards. Matter of Concern 2: There were deficiencies by the investigating officer and SYP in relation to the investigation into the allegation of sexual assault. It is accepted that the initial investigation into the allegations made by Miss Greene were not investigated to the standard expected by South Yorkshire Police. After the tragic death of Miss Greene, the allegations were reviewed and the reviewing officer concluded, this investigation appears to fall well below the standards of what would be expected when serious sexual allegations are made by a 13yr o/d girl against a male suspect who was 18 at the time. The review also established that the decision to file the investigation was inaccurately recorded and lacked rationale, with the reviewing Detective Inspector not having a full oversight of the investigation and actions undertaken by DC This review led to the allegations being reinvestigated and the case submitted to the Crown Prosecution Service. South Yorkshire Police have processes in place to ensure that all investigations on allocation to an OIC have a clear investigation plan, this includes guidance to the OIC around evidential actions, lines of enquiry and safeguarding. Vulnerability is also assessed with guidance around support services that are available to the victims and other parties involved. The investigation plans are completed by Sergeants and are recorded electronically on the investigation. There is further supervisory oversight every 28 days; again this is conducted by the first line supervisor who is a Sergeant. There is further review of the investigations every 4 months by an Inspector. As a minimum, the Force expects the following to be considered and recorded during the review process:
1. Victim safeguarding and contact - both actual and future — e.g. what have you done / what referrals have been made? What does the victim contact regime look like? Is it sufficient for the crime type and is it being followed?

4
2. Suspect Risk — both now and future - e.g have you assessed the ongoing risk posed by the suspect, what is your decision making around arrest / circulation and why?
3. Investigative priorities - is there an investigative plan — have the actions been addressed? If not why not? How will you remedy this?
4. Should we investigate - is there a crime? Should we investigate? If not why not? If not, can the crime be filed?
5. Due diligence — is the investigation being conducted with due diligence. If not, who or what are the blockages? How long will it be for these issues to be resolved or finalised?
6. Future reviews and supervisory governance — who is to check on whether this investigation is being progressed? Will there need to be an interim Inspectors review to ensure momentum?
7. Support Agencies — Does the victim require referral to a partner agency such as Social Care, ISVA or IDVA services or counselling. An assessment of the quality and efficacy of the investigation review process has recently taken place. All crime mangers have been reminded of the process and have been requested to cascade this process to all supervisors. Compliance with the investigation review process in terms of both timeliness and quality is subject of regular scrutiny and performance reporting. The CID 40 Sexual Offences booklet used by officers attending the initial report of sexual offences has been reviewed and updated. This booklet acts as an aide memoire for officers and includes information around victim care, officers' actions and suspect management. The revised booklet is currently being distributed across the Force, and the necessary amendments are also being made to the Force intranet site. A copy of the new booklet has been attached for your reference. The investigation undertaken by D as referred to the Independent Office for Police Conduct and their assessment remains ongoing at this time. Matter of Concern 3: There was lack of clarity around the BSARC referral and its actioning. The SARC (Sexual Assault Referral Centres) support service covers all four areas of the Force. Barnsley is covered by the BSARC service. The referral process for victims of sexual offences is in place for officers and staff to make a request for support via the professional's portal central on the BSARC webpage. These referrals are sent and allocated at the central hub for ISVA/ CHISVA service, located in Doncaster. It has been identified that the referral officer does not receive any acknowledgment that the submission was successful. It has also been identified that different officers used alternative referral processes such as direct emails to ISVA managers and phone calls. The direct and single point of referral has been reinforced to all officers via the Force intranet page signposting them to the current process and to ensure they have a full understanding of that process.

5 The current process for officers, as highlighted below, is found on the dedicated PVP page on the Force intranet or the individual SARC service internet pages. Independent Sexual Violence Advocacy The ISVA (CHISVA for Children) service helps anyone who has been the victim of unwanted sexual contact offering practical support to deal with circumstances. Their aim is to help give people the confidence, support and information they need to take control of the situation and move forward. The CH/ISVA will establish the needs of the person and put support plans in place. Working with other support agencies such as: o Health services & Emotional wellbeing;

Liaising with schools & education; o Housing & Benefits; 0 Therapy. The CH/ISVA will work with the Police and the rest of the criminal justice system. Examples of the type of support we will provide include: o Liaising with the police, courts, Crown Prosecution Service (CPS) and other public agencies; o Keeping the client informed of developments in the case;

Advocating on their behalf;

Supporting before and during any court case. How to refer to the CH/ISVA Service: Complete the form on this link: https:/(isva-referral.drasacs.org.uk/ Under the Victims Code, the 'explicit consent' of the person being referred is required. If the referral is for a child, the consent of the parent/guardian must be obtained. The services are delivered locally in Sheffield (SRASAC), Rotherham (RothACS), Barnsley (BSARCS) and Doncaster (DRASACS) by the four providers that are part of the South Yorkshire Sexual Violence Partnership, with all referrals being managed at the central Hub in Doncaster.

The force and the commissioned ISVA services are working together to improve the referral process, ensuring that referrals are acknowledged by the ISVA service along with the development of a form in which the officer will complete with the consent of the victim and then forwarded to the ISVA service. Officers will be directed to electronically record the submission within the investigation along with follow up enquiries with the ISVA service to ensure the victim is being supported. This document will be incorporated into the revised Investigation booklet that has been developed for attending officers, to support them whilst dealing with rape and sexual offence investigations. Work is ongoing with the SARC service to provide officers with a confirmation of a referral request being received. When this is in place, officers will be instructed to add this to the investigation record. Matter of Concern 4: That Emily was never personally seen to sensitively explain the fact of and reasons why the police were not going to take the allegation any further.

6 It is accepted that Emily should have been seen face to face to explain the decision not to take the matter any further. In 2017, the Force had in place a clear Victim Codes of Practice (VCOP) policy on which all officers are fully sighted, the policy is supported by booklets to be distributed to victims of crime, it is accepted that booklets with bespoke information may not have been readily available at that time to provide to Miss Greene and her family. Since this time the framework of Complete Victim Care (CVC) has been developed resulting in significant improvements in how the Force provide victim care. The force has a dedicated theme lead along with a regularly updated intranet page and a victim care booklet. The current booklet entitled 'Supporting Victims' contains information for victims and allows the officer to record their contact details and the next steps of an investigation. Within the booklet, there are details of support agencies available including support for victims of both sexual abuse and domestic violence. The Victims Right to Review (VRR) process is explained within the booklet detailing that the process came into effect on 1 April 2015 and applies to all recorded crime offences. The VRR section further details under what circumstances a review can take place and how the process is undertaken. The section quotes, the intention of the scheme is to give you a way to appeal a decision not to prosecute. The right of a victim to request a review happens where the police: e Make a decision not to bring proceedings in cases where the police are able to charge or

Make a decision that the case does not meet the relevant threshold for referral to the CPS for a charging decision. You are allowed to request a review within three months of being notified of the case being filed, as this is the period during which they can request a judicial review. Within the force intranet page, there is the force document under VCOP on a page where the officer is given guidance of the process and the expectations of the force in relation to victim care. Some of the key areas from the page are below. Update victim Update the victim within five working days or within ono day enhanced victlm, if a suspect is:
• H+legsed Without charge
• Char," to o,' ot
• If the CPS not to
• Other updatea to be provided Ot regular intervals following discussion with the victim
• Neco,'d that the victim has teen
• Outline Pollcc Victim Right to and CPS Victims Rloht to Review Scheme. First contact with victim
• Complete astez;rnent to enhanced vitt:ms
• and complete Victims bc.okk•t (this

done contact or no tctcc than five days after •.hc first to download the Oc•oklet Via our

501.tthyork5.pollco.uÅ
• victim that their detail' will be pasted on to Victim Support Services (VSS), the victim ESP-tan d that th%' can attn the at any time
• Victims don•t havo to updates from any within the VCOP. they cut. emplain and record. They can opt in at M'/ time by con:actng the CIC VS$
• It is the choice. not yours, whether they wloh for their detuils to be pussed to VSS
• Record crime within hours.

7 Enhanced victims Victims of most seftus crimes aæ; a close relative bereaved by a criminal offence. a victim of domestic væce, hate crime, terrorism, sexual offences, human trafficking, attempt murd% kidnap, false imprisonment, arson with intent, wounding or causing GBH with intent (sec18 offences only) ' targeted victims are those who have been targeted repeatedly asa direct victim of crime over a period of time, padiculaiy if they have been deliberately targeted are victim of a sustained campaign of harassment or stalking
• Vulnerable and Intimidated victims those defined by Section 16 and 17 Youth Justice and Criminal Evidence Act 1999. The force's management of victim care is monitored on a regular basis through victim care satisfaction surveys along with being reviewed and discussed at quarterly District performance days. The learning from this case has been discussed with District Commanders to ensure qualitative review takes place. Ms Greene and her family would have been entitled to the enhanced victim service and it is accepted that DC— did not provide this to the family. It is also accepted that DC provide the family with the any information in relation to the appeal process. It is accepted that DC—should have seen the family face to face, and in particular Miss Greene, to explain the rationale as to why the matter was not progressing to the Crown Prosecution Service. It should then have been explained that they could appeal this decision with the District Crime Manager who holds the rank of Detective Chief Inspector. The force will ensure all officers are fully sighted in the appeal process and ensure that the CVC booklet is provided to all victims of crime. Matter of Concern 5: There was (and I understand still is) lack of a suitable room for taking the victim video at Wombwell police station (due to a parent not being able to be accommodated) The Achieving Best Evidence Guidance (ABE) issued by the Crown Prosecution Service (CPS) provides guidance to officers in relation to having other persons present in the interview room. This guidance states that Interview supporters can be present in the interview room if it is deemed necessary and would provide emotional support to the victim. This would only be if appropriate and practical: Parent(s)/carer(s) should not be automatically excluded from this role, but their appropriateness will very much depend on the circumstances and nature of the case, together with any issues arising from the allegations made by the child. There are also good reasons why their presence may not be in the best interests of the child. Research suggests that the presence of a carer or parent at the time of the interview can actually be an additional source of stress if the child is concerned about them hearing unpleasant details. Victim Support
• Police team sends referrals of all recorded crime incidents (excluding domestic violence) to Vctim Support by automatgc date transfer on a dad}' basic
• VS ease management system performs vulnerability based automatic triage. All vtct'ms cf sexual offences ate forwæ•ded to the South Yorkshire Independent Sexual Violence Partnership for initial contact, triar and support
• Victims eat't!ed to enhanced zenices {in line with VCOP/ dtrectea to VS Cope & Recovery' team and a'lccat±d a Vtctvrn Care ACvocete (VOA). to make phone contact within 24hrs. complete a needs and risk assessment. the

end otte support
• Support required; VCA acts az a single point of contzct throughout cnrnjnal justice process. coord/nating v;ctirn cate w•ith multi-agencies. Provide advocacy services, information about CJS and emotional support to "Sist victims, cope and tecover the Impact of come
• Vict.ms not entittea to enhanced service sent auto text with VS contact detai)s, web telephone access
• Victims agents can to

Support at any point in time following a Incident.

8 In addition, the child might feel uncomfortable about someone they see on a daily basis, knowing intimate details of their personal life. Other witnesses in the case, including those giving evidence of an early complaint, cannot act as interview supporters. Further guidance can be found in the below national CPS document.

proceedings.pdf Miss Greene did make a first disclosure to her mother resulting in her mother being a witness, and on this basis, it would have undermined the evidence and gone against the national ABE guidance to have allowed her in the room. The ABE interview of Emily took place at Wombwell Police station, which was fit for purpose. The ABE room contains seating for the victim, officers and any third party such as an interpreter or intermediary if it was identified the victim required one. There is a waiting room very close to the ABE room where parents or other people who are there to support can wait. An officer would explain to the parent and the child that should they become distressed, the interview could be paused and the officer would offer to ask the parent / carer to offer support to the victim. South Yorkshire Police has 10 Achieving Best Evidence rooms within the Force, all of these are fit for purpose but there is currently a programme of refurbishment taking place to enhance them. Four sites have been refurbished in the current financial year and there is a plan to refurbish all remaining ABE rooms, including Wombwell, over the next financial year. There have been delays in this work due to the COVID 19 restrictions. Matter of Concern 6: There was mishandling of the missing person report. South Yorkshire Police would refer to the evidence of which provides the following summary; On the 13th November 2018, 3 days before Miss Greene was reported missing, the Force introduced a brand new incident management platform, called 'Smart Contact'. A full review of the reporting of this incident was undertaken and it established that the operator within the communications room was grading the call on the standards and processes relating to the previous management system. The initial calls by the family were received by West Yorkshire Police and redirected to South Yorkshire Police. The incident created at 19.39hrs was graded as 'Resolve Without Deployment' (RWD). This grading would mean that the incident would be dealt with solely over the phone. It was identified at 20.56 as being graded incorrectly and it was regraded as a priority. The priority grading means a response time of 60 minutes should be met. It was established within the review that the incident remained unallocated for a further 71 minutes at which time resources were allocated, however there were further delays before officers arrived. In total, it was 3hrs and 3 minutes from the initial call to officers arriving at the home address of Miss Greene. This time is not what is expected of either the Communications room staff or attending officers for this type of incident.

9 The new incident management system is now fully embedded within the Communications Centre and all staff are fully trained, understand and are familiar with the grading process. Staff receive ongoing developmental training. The force is due to implement a new 'missing from home' IT system called 'Compact' which will improve the forces management and recording of persons reported missing. This new system commences in April 2021.