DEPARTMENT FOR WORK AND PENSIONS RESPONSE TO REGULATION 28 PREVENTION OF FUTURE DEATHS REPORT ON FAISA HASSAN AHMED Introduction This report fulfils the Department for Work and Pensions' duty to respond to a Prevention of Future Deaths report made under the Coroner's (Investigations) Regulations 2013. This request has arisen following an inquest which reported on 20 January 2016 into the death of Faisa Hassan Ahmed: Ms Hassan Ahmed was a former claimant of Jobseekers Allowance, who took her own life on 7 November
2014. The Department takes seriously any declarations of intention to attempt suicide or self ham that are made by its customers and has put in place a well-designed process that seeks to ensure appropriate action Is taken: There is a clear; detailed six point action plan that staff must follow if a customer declares an intention to kill or harm themselves. In addition, DWP provides both guidance and training to help staff deal with these incidents. The policy, procedures and guidance are reviewed regularly to ensure that continue to meet thelr objectives and to identify areas for improvement: This report is structured in three parts. The first describes the current system for managing threats to attempt suicide and or self harm. The second provides a summary of the circumstances in Ms Hassan Ahmed's case: The final part describes what systems the Department has in place continuously to improve its processes to support those who threaten to attempt suicide and self harm, including how it deals with the consequential impact this may have on DWP staff. The current process for managing threats to attempt suicide or self harm The Department deals with a wide range of customers who at some point in their lives may be vulnerable because of Iife events or disability. Providing the right level of support to enable these customers to access DWP benefits and use DWP services is major commitment To this end the Department has agreed a common definition of vulnerability as being any 'individual who is identified as having complex needs andor requires additional support to enable them to access DWP benefits and use our services: This ensures consistency and continuity in the delivery of our services to those who are vulnerable: The Department's staff are trained to recognise the signs of vulnerability and to respond appropriately: This policy includes they '"

ensuring the Deparlment's staff are vigilant to customers who may directly declare , or whose behaviour indicates, an intention to attempt suicide or self harm: Extract from DWP national guidance for all staff: "Managers, in all DWP businesses who work with customers; must use the Departmental National Point Plan framework t0 develop arrangements that suit their own local working environments to help staff deal effectively and safely with customer declarations of intention t0 attempt suicide and self harm. The Departments staff are not medically trained. Therefore it is important that there are systems, procedures and responses in place to provide support to staff in the event that a customer says intend to harm themselves: Consequently, managers throughout DWP are expected t0 develop arrangements with staff that comply with the principles of the DWP Six Point Plan framework and to produce their own localised Six Point Plan. A copy of the Departments guidance which includes the Six Point Plan Framework Is attached at Annex A. The locally developed version for Poplar Jobcentre where Ms Hassan Ahmed claimed JSA has also been attached at Annex B. The Six Point Plan In brief;, the Six Point Plan framework is as follows;
1. Take the statement to self or suicide seriously remain calm and Iisten carefully: 2 Summon colleague to act as a support partner:
3.0 Gather infomation to gauge level of risk:
4. Provide referral advice _ if situation is non-urgent; e.g. general distress but no immediate plans or means to attempt suicide or self harm_ 5_ Summon Emergency help ~ if customer is distressed, at serious risk or in immediate danger: 6_ Review discuss incident with line manager and record The arrangements which are put in place will be as comprehensive as possible t reflect different interactions with our customers, whether through face to face communications, telephone calls or written correspondence from customers (including emails): These support arrangements also extend to members of staff who work away from the ofiice, including those who visit customers in their homes. Once the Six Point Plan is in place for the individual office, the Department's managers will ensure that staff regularly refresh their knowledge of processes and procedures and have the capability to know how to respond appropriately t situations arising: This level of awareness Includes access to both detailed guidance and formalised training to help staff gain and refresh their knowledge. 2 Six they harm

Ms Hassan Ahmed's Case Faisa Hassan Ahmed was due to attend Poplar Jobcentre on 4 November 2014 to make her declaration of unemployment in order to remain eligible for her benefit payment: However; she contacted the Jobcentre that to say she was sick: Faisa subsequently attended the Jobcentre on 7 November 2014 where she explained to the Work Coach that she had not come in on 4 November because she was ill. She was asked to complete a fom to fomally declare her sickness on 4 November. Faisa completed and returned the form to the Work Coach, then immediately left: This meant that the Work Coach was also unable to discuss the detail of the statement she had made; 'Iwas busy trying to kill myself, drinking non-stop'. On the form Faisa stated the period of illness had occurred between 4 and 7 November The Work Coach discussed his concerns with his line manager, invoked the Six Point Plan, and recorded the incident in accordance with DWP procedures DWP policies state that its employees are empowered t0 take any reasonable steps , including contacting the emergency services, if feel the customer faces clear and significant risks to their welfare or safety: In this case, based on the information he had, the Work Coach made a judgement that there was no immediate risk to her safety: The information available to the Work Coach at that point was based on the form that Faisa had completed, stating a period of illness between 4 and 7 November which was now ended, and the fact that she had attended the Jobcentre to make her declaration to receive her benefit: Sadly, Faisa died at Westferry station later that same Reviewing the Processes As with any public facing organisation, it is always possible that DWP staff may encounter customers who might say they intend to harm or kill themselves. This can also be a distressing experience for DWP staff and their other customers. So it is important that staff know how to manage such an event t0 reduce distress and achieve an outcome where everyone is safe_ We expect staff to be alert to customers who may directly declare, or whose behaviour Indicates, an intention to attempt suicide or harm and to be aware of the Six Point Plan and to use this as a basis to enable them to manage situations that may arise effectively: This localised Six Point Plan must be developed then regularly reviewed in consultation with the Department's Trade Union representatives to ensure it continues to meet its objectives and for continuous improvement purposes. Staff awareness is further underpinned with bespoke learning to support them when dealing with all vulnerable customers. An example of how this learning supports day they day. self

raising the awareness of customers threatening suicide and/ or self harm is attached at Annex C. This is drawn from one of our national learning products Supporting Customers With A Vulnerability. At a national level, the policy and guidance are reviewed regularly to ensure they continue to meet their objectives and for continuous improvement purposes. DWP uses a variety of internal communication channels to ensure staff remain aware of all changes to its guidance and processes as they occur; Conclusion The situation that has given rise to the requirement for this response is extremely sad and our condolences and sympathies go out to Ms Hassan Ahmed"s family for their loss. Nevertheless, in this case we feel that the Departmental processes around managing the threat of suicide andl or self harm were followed both diligently and correctly: In recognition of the risk, DWP staff took the necessary steps t0 invoke the agreed processes that would manage the risk appropriately: Importantly this action was based on the evidence that staff were presented with. It is not our view that any opportunity to engage with any other organisations was missed: As the information we have set out in preceding paragraphs shows, the Department's approach t0 managing threats to attempt suicide and self harm is under continual review and development and we do treat them seriously. Such internal mechanisms provide a valuable method of refining the processes being applied as well as helping to identify opportunities for improving supporting products Iike those of learning and development which help to build staff capability. Therefore as part of this continued review, we will now be taking the opportunity to issue a reminder to all DWP staff about the guidance related to suicidal ideation that has been described in this report

Dear Ms Hassell Regulation 28: Report to Prevent Future Deaths-Faiza Hassan Ahmed Thank you of your Regulation 28 Report to Prevent Future Deaths dated 20 January 2016, bringing to my attention matters of concern encompassed within the jury's determination: The Trust can confirm the Emergency Medical Dispatcher (EMD) noted on the call that the patient "wanted to die" , thereby indicating her suicidal intent; but this particular piece of information was not conveyed to the crew. Unfortunately, this was an individual error and all EMDs are trained to tag and pass pertinent information to the attending crew. However, the information which the crew were given was "Psychiatric/Abnormal behaviour/Suicide attempt; Trying to slit wrists; Armed with weapon-glass; therefore the crew were given adequate information of Faiza's suicidal intent_ Since the incident the crew involved undertook Reflective Learning and Clinical Update was published in April 2015 reinforcing the assessment of Capacity. This was disclosed at the Inquest in evidence about the Serious Incident Report and the actions arising from the incident: On 7 September 2015 a new Operational Management Structure was implemented which introduced a Stakeholder Engagement Manager role for each sector of London_ This role consists of liaising closely with other stakeholders, including the Metropolitan Police to discuss issues of wider concern for that particular Borough. Issues of concern can include frequent callers , community events, and resident issues: In addition, a new role of Quality Assurance & Governance Manager has been implemented in every sector. Part of this role is to process and develop specific Care Plans for Category 4 patients _ These patients are those with an underlying medical condition and in need of a differentlalternative care plan than the wider public. Furthermore, the LAS have allocated funding for Mental Heallh Nurses to work in the control room. Currently the Trust has filled 4.5 posts and has an on-going recruitment to fill a further
1.5 posts within the next 6 months_ Their role is to provide telephone assessment from speaking with the patients and provide advice to crews on scene. In addition the Mental Health nurses are skilled at referring patients directly to crisis teams or appropriate pathways for patients with mental health needs log the

hope this reply is helpful in explaining the actions taken to address the matters of concern: In closing wish to offer my condolences to Miss Ahmed's family:

Dear Ms. Hassell; write on behalf of the Metropolitan Police Service in response to your Regulation 28 Report to prevent future deaths dated 2Oth January 2016, This was prepared following the inquest into the death on the 7th November 2014 of Ms Faiza Hassan Ahmed, which was opened on IIth November 2014 and concluded before you and a jury on 2Oth January 2016,at St Pancras Coroner's Court_ Background You will recall that the proximate cause of death was injuries sustained by Faiza Ahmed stepping in front of a train, following contact in the two days prior to her death with the Metropolitan Police Service (MPS) , the London Ambulance Service (LAS) and the Poplar Job Centre. You concluded that she killed herself Matter of Concern You stated that: The matters of concern are encompassed within the jury's determination_ We note that the jury gave a narrative verdict; commenting on a number of aspects of the case pertinent to parties in contact with Ms Ahmed prior to her death; will confine myself to consideration of those points directly or indirectly concerning the Metropolitan Police. If | may excerpt these from the narrative: the morning of 6 November 2014, Faiza reported that & man had attempted to rape her in her home_ The historical and continuing lack of rapport between Faiza and the police contributed to her not receiving the support she needed follawing this incident: "On

2 "The period of time elapsing between the sexual offences investigative techniques (SOIT) officer's first and second attempt t0 make contact with Falza meant that she never received specialist support from the Sapphire Unit:"
3. [on 7th November 2014 Faiza made two declarations of suicidal Intent; t0 & Job Centre, and t0 the London Ambulance Service via a 999 call. Police were informed of only of the second of these, and attended ] lack of rapport between Faiza and the police officers and LAS crew on the scene hampered the provlslon of support t0 her: Two SOIT officers arrived shortly after the police &nd LAS, but did not see Faiza: "The Information they had about the previous day's report of attempted rape was not adequately conveyed to the pollce response team and was not conveyed at all to the LAS crew: This left both insufficiently Informed t0 fit their response to Faize'$ needs:
5. "Throughout the two days, Information held on police databases about Faiza's history of vulnerability was not relayed to any of the police and LAS personnel who dealt wlth agaln leaving them Insufficlently Informed t0 fit thelr response to Falza's needs:" MPS Response Preface In drafting a response to these points the relevant subject area experts have been consulted. These include: Detective Superintendent] Sexual Offences Exploitation & Chlld Abuse Command; with Chlef Inspector Professional Standards Champlon for Met CC (Central Communications Command, responsible for call handling); with Chief Inspector of the Territorial Policing Mental Health Team; and Detectlve Inspector Iresponslble for the MPS Natlonal Mental Health Policing Portfolio. have also drawn on the findings of 'Operation Indigo' , the internal Metropolitan Police Speclalist Investigatlons review Into the events; and the findings of three further documents, all of whlch we belleve you have had sight of. The first of these, the 'Independent Review Into The Investigatlon and Prosecution of Rape in London" was commissioned by Sir Bemard Hogan-Howe, the MPS Commissloner, In May 2014 and undertaken by Dame Elish Angiolini DBE QC. The report of the review was published in April 2015,and made 46 specific recommendations, both for the MPS , and for the Crown Prosecutlon Service, deslgned to Improve the service provilded, from initlal investigation through t0 offender prosecution; to victims in all cases of sexual offences: As | belleve you are aware, at the time of Ms Ahmed's death in November 2014 the structural concemns Identifled In the Angiolini Revlew had all been accepted and were already being addressed in some depth through the ongoing work outlined In the second document of relevance here, the Joint Crown Prosecution ServicelMPS Response to Dame Angiolinl's Review: , https Ilwwcps gov ukIPublicationslequalltylvawldame_elish_anglolinl_rape_revlew_2016.pdf https Ilwwwcps gov uklondonlassets/uploads filesldame_elish_Joint_response pdf her, prior

These recommendatlons have in tum fed Into the ongolng work of the thlrd document referred t0 here, the Jolnt National Rape Action Plan, Inltlated on 6lh June 2014,and likewise, published in April 2015. The followlng Is based on a review of these documents, and other relevant sources, by Detectlve Sergeant] Directorate of Professional Standards Organisational Learning The above subject area experts have, In turn, reviewed this response: Neither nor those consulted have had sight of transcripts of any oral evldence from the inquest itself; so in the event of any variance between reported facts and evidence you know to have been presented during the inquest Itself;, defer to your knowledge. Dates, relevant partles and communications have; where possible, been confimed by reference to emails, minutes of meetings, published policles, intranet communications or other documents: The details of the poor rapport reported between Faiza Ahmed and the police, and Issues of infomation sharing between the police and the other agencies concered were explored during the inquest itself, Many of these issues were partlcular to the facts In this case, rather than offering genaral insight pertinent to systemic practices of the wider organisation, and | do not therefore propose t0 revisit them In great detall here: It is slgnlficant t0 note that the broad thrust of the jury's critlcisms might be summarised as two complementary Issues; communlcation between relevant partles of knowledge regarding Ms Ahmed's situation; and the difficulties attending officers had in achieving useful rapport with Ms Ahmed, Concern Response: Points 1 & 3 above, rapport; polnt 2, SOIT engagement To deal with the Issue of rapport first: it is Important t0 acknowledge that factors other than the abilities of the particular officers In attendance to Ms Ahmed In her final may have had a role in this. For example, her previous troubled personal history of contact with police has been widely reported in the This history may have influenced her willingness to engage on these final occasions. The findings of the intemal police investigation, Operation Indigo, bear out some of the dlfflcultles encountered, whilst at the same tlme maklng It clear that attending oficers In the final encounters indeed attempted on each occasion to achieve meaningful contact; albeit with a person who undoubtedly presented a challenge to rapport- building: For example, the Operation Indigo author describes pollce response to the initlal allegatlon of sexual assault made by Ms Ahmed, on Thursday 6" November 2014, the before her death, (para 4.2.21-23) PCL Jone of the flrst-responding officers, on encountering Ms Ahmed outslde her address, noticed blood on her clothing; and, qulte properly, attempted to persuade her to allow police to seize the clothing for forensic examination, and to dissuade her from immediately returning to her home, the apparent crime scene: Both of http llwww cps gov uklpublications/equalltylvawlrape_action_plan_aprll_2015-pdf
0.g http llwww.theguardlan comluk-news/2016/feb/oalfalza-ahmed-crles-for-halp-migsed-avery-authorlty- simon-hattenstone?CMP-Share_IOSApp_Other prlor days press" day'

these measures were best-practice steps designed t0 advance effective investigation: It Is acknowledged however that a third party witness' , commenting on the exchanges In which the officer attempted to obtain a clearer plcture of what had actually occurred, nevertheless expressed 'surprise' at the Intrusiveness of the questioning; conducted by a male officer with Ms Ahmed in a public area; a less than Ideal situatlon. The guldance document 'Rape and serious sexual assault First Responder checklist ;, available for reference for our officers 24/7 vla the MPS Intranet, advises instead: [taking a victim] t0 & comfortable and prlvate walting area The witness added that, although the officers' questlons were not in any way Inappropriate, and the offlcers had explalned to Ms Ahmed why needed to ask them, she would herself have felt 'uncomfortable' answering such questions, in such a way: (para 4.1.12) The initial questioning itself however was in line with best practice. Sufficient details must be obtained t0 understand what Is belng alleged; where and when it has occurred, and who the principal parties are. Meanwhlle the second initial attending officer; PCI sought advice, vla local Ilne management; from the on-call specialist 'Sapphire' Central Sexual Offences Investigation Team Detective Sergeant; DST regarding how best to proceed with the agitated Ms Ahmed, who Infoned the officers that she had been drinking throughout the preceding nlght In Iine with current best practice, PCI a (female) Sexual Offences Investigation Trained ("SOIT) officer; was tasked by DS) with attending Ms Ahmed; It was clear that there was some tension between the desire on the part of the Initlal attending response officers to achleve best evidence, and the manner and location of the communication between Ms Ahmed and those officers, necessitated by the character of the contact between the parties. Despite these difficulties, however; it is worth noting that a degree of initial rapport was nevertheless established, to the extent that the attending officers obtained sufficlent detail of the alleged offence and offender to circulate a description of the suspect; who was then promptly arrested by colleagues nearby: In light of the evident difficulties at the scene it was Inltially proposed by DS (that the meetIng with the speclalist SOIT officer would be at Limehouse Police Station, which was equlpped with a 'Comfort Suite' _ Comfort suites are dedicated rooms within police stations where victims of rape and sexual assault can talk to police In privacy and comfort. It Is accepted that some areas within police stations may appear uninviting or intimidating for victims, s0 these comfort suites have been designed as comfortable and private places to help put victims at ease when reporting these offences: As the venue for the sexual offences speclallst to obtain a more detailed account was to be a police gtatlon;, it was also initially felt that a single ofiicer could safely deal. PC] prepared t0 make her way; without her personal protective equipment ('PPE' stab proof vest; baton, handcuffs, CS spray): As the Indigo report goes on, however: stated [Ms Ahmed] walked off towards her flat and he followed trying t0 prevent her entering: Once outside the address he and PCL tried t0 neighbour, enlisted by the officers in an attempt t0 overcome Ms Ahmed's verbal hostlity toward them they from

explaln to her why the scene needed t be preserved but she continued t0 be obstructive: He stated Faiza continued t0 demand that she be allowed t0 enter her flat &nd threatened to klck her own door down. Eventually she used her keys to enter the address and closed the door on the officers: PC stated that he left the scene after she had entered her address" [ibid , para 4.2.22] DST received the infommation that Ms Ahmed was no longer cooperating with officers at the scene:. Research had also indicated Ms Ahmed was capable of being volatile and violent when intoxicated: Reports for example Indlcated she had assaulted pollce In her home flve months earller when had attended there to check on her welfare: Based on the information he had available, therefore, DS] made a dynamlc risk assessment that a meeting with Ms Ahmed in her present state of mind was no longer suitable for an Immedlate single SOIT deployment; and instead arranged for PGE re-attend Ms Ahmed's address with a colleague the following 7u November: This declsion was thus directly responsible for the Initial delay In the assigned speclallst, female SOIT ofiicer making contact with Ms Ahmed, whlch was commented on adversely by the jury at point (2) above: Was this a reasonable decision, in the light of all the circumstances? The so-called 'Golden Hour' principal of investigation rightly emphasises the Importance of prompt evidence preservation, 'fast time' enquiries etcetera, undertaken In the immediate aftemath of a reported Incldent: However; we also train all our officers In the National Decision Modele, cognitive tool designed to offer a coherent structure for explaining what was done during any incident and why; for use both at the time by practitioners, and subsequently, as an evaluation tool for examiners of the decisions made. One arm of this model is explicitly dedicated t0 risk: 'Assess threat and risk and develop a working strategy' . Applying thls model to the declslon made by DS las the responslble supervisor; then: It is apparent he had to conslder, not only physlcal risk to hls officers, but also practical threats to the developing investigation; Thus elements to be considered would include the fact that PC did not have her Personal Protective Equlpment with her; (an admitted oversight whlch the offlcer has slnce been spoken to about); but also that she would in any case at that tlme have been a solo officer attempting to deal with a demonstrably recalcitrant victlm who had, by her own account;, been steadily drinking for some conslderable time prior to police arrival; one moreover with a documanted history of aggressive behaviour toward police. These factors would have to be weighed alongslde the fact that Ms Ahmed, In returning to her flat and excluding police from it against advice had already potentially compromised scene preservation; whilst other officers responding to the call, actlng on the basis of the minimal Information then available, had taken positive steps to arrest the suspect for the offence. So, some aspects of the investigation as a whole were moving forward; an Immediate threat to the victim had been addressed; whilst other elements were already potentially compromised; and the dlfilcultles encountered in achlevlng immediate rapport with the victim were now known. https Itwww app college pollce:uklapp-contentnational-decislon-modellthe-nalional-decision-modev they day; Friday `

Guldance on judglng the decision making often required of police officers in dlfficult circumstances such as these notes that attention should be paid to the quality of the decislon making, (which is within the control of the police). not the outcome, (which is not): In this case, the chief element of rlsk; the suspect; was for the moment ellmlnated: Olher matters to some extent had been taken out of pollce hands through Ms Ahmed's own refusal to engage, possibly exacerbated by alcohol, which might also impact on her ability to provide a detailed statement immediately: In this context; the declsion to delay the SOIT contact untll she mlght prove more tractable to a recovery of rapport, to have recovered night's drinking, and the officer safety aspect covered by sufficlent control measures (the deployment of second ofiicer, availability of correct PPE) t0 mitigate physical risks can therefore be seen to be a rational one: Unfortunately, as other uniformed officers responding the following to Ms Ahmed's separate call to London Ambulance Service threatenlng self harm found, the passage of tlme had not wrought the hoped-for change In Ms Ahmed'$ demeanour: [Ibid. paras 4.13.4-9]: "On arival the front door t0 number 22 was closed so [PC knocked several tlmes before a female voice from withln said "Who Is 1t?" He replled "Its tho pollce: Can you open the door please?" The female replled "Everything Is fine. There is no crime here" He said you open the door as don't want to force it open: We just need to speak with you that's all The door was opened by & female later Identifled as Faiza Ahmed. She said "I dontt need you lot: You can fuck off. PC stated that he explained were asked to attend on behalf of the London Ambulance Service as they had been contacted by someone threatening to harm themselves with a plece of broken glass: Faiza Ahmed replied "Well Its not me. I don't need you Iot here. Inever asked you to come SO can you please fuck off. He replied "Have you hurt yourself with some glass?" She replied "No". He said "What's your name?" and she replied "You don't need to know my name all on your systems:' PC stated that he saw a letter and & bank card on the sofa which confirmad her name as Falza Ahmed. He stated he sald "Have you called for an ambulance?" and she replied "No. I dontt need an ambulance and | don"t know why you are here He said "Could anybody else have called an ambulance for Have you phoned a friend or anybody t0 say you were going to hurt yourself with some glass?" She replied #No. Look / never called you Iot please fuck off: The Indigo report recounts PC Icontinued to attempt to persuade Ms Ahmed to allow the officers Into the premises, to engage with her regarding her mental state and medical treatment, and t0 conduct what risk assessment he could of her mental capacity, physical health, and levels of risk presented by her state of mind , evidence of alcohol drinking and her Immediate environment: [paras 4.13.10-15] He then continued to remain on scene whilst the ambulance crew arrived, and took over the lead In the continuing attempts to rapport-build, only for the LAS personnel t0 experience similar difficulties. [para 4.13.16] rapid from her day " "Can they ' Irs you? how

It was durlng thls perlod also that the Sexual Offences Investlgatlon Trained officer PC land a colleague attended; having postponed thelr Inltial planned visit from the previous after Ms Ahmed's initial refusal to engage, and the resultant dynamic risk assessment conducted by DST On this second occasion too, having been briefed by PcE regarding Ms Ahmed"s state of mind and volatllity, and by the LAS regarding her nevertheless evident mental 'capacity' and lack of immediate welfare concems, all parties once again decided to leave. [para 4.13.20] It Is acknowledged that no officer present claims to have briefed the LAS crew regarding the details of the alleged sexual assault call from the previous day [para 4.13.21]. In fact; the only officers capable of dolng this would have been PC and her colleague, as at this point the uniformed response officers were themselves unaware of the earller call: This was arguably regrettable, as knowledge of the circumstances may have gone some way to explalning Ms Ahmed"s earller call and attitude toward the proffered assistance on this second occaslon: It Is by no means clear however what dlfference, If any, thls knowledge would have made to the practical options open on thls second vlslt to either police or ambulance personnel. Pc) land her colleague for example did have this background Inforatlon; but it did not alter their operational decision to withdraw without speaking to Ms Ahmed: Of perhaps more consequence, was the decision these professionals collectively agreed upon regarding Ms Ahmed"s mental 'capacity' , since this sets definite limits on the ability of state agents guch as the police and medical staff to Intervene In a person's private life against their will: The concept Is defined at Section 2(1) of the Mental Health Act 2005: ~a person lacks capacity in relation t0 & matter if at the material time he is unable t0 make & decision for himself in relation to the matter because of an Impairment of, Or a dlsturbance In, the functionlng of the mlnd or brain. Section 3 of the same Act elaborates upon the nature of the relevant test: "3(1) For the purposes of section 2, & person Is unable t0 make & declslon for hlmself if he Is unable (0) t0 understand the Information relevant to the declslon, (b) t0 retain that information, (c) to use or weigh that information as part of the process of making the declslon; or (d) to communicate his decision (whether by talklng; uslng sign language or any Other moans): Responding to concerns regarding_the limits of pollce action In an earlier case involving a vulnerable Chlef Inspector_ Territorial Policlng Mental Health Team gave consideratlon to the limits of police actlon whan dealing with persons who may be suffering from mental Illness or some other temporary or permanent reduction In their 'mental capaclty' , but who have othenwise committed no offences. Police powers in these situations Inquest of Finnulla Catherine Martin, 19/11/14 day; adult? ,

are governed chiefly by elements of two Acts; Section 136 of the Mental Health Act 1983, and the Mental Capacity Act 2005. Regarding Section 136, CE notes: "[This] only gives officers powers to detain persons in public; [my emphasis] and in 'immediate neod of care and control', a hlgh threshold; whllst powers to detaln persons in private places, deemed by on-scene quallfied mental health professionals to be 'in need of Immediate care and control' , can only be engaged vla & warrant obtalned under Sectlon 136 of the same act; More recently the Mental Capacity Act 2005 gives officers some limited protections from llability should an indlvldual officer, at the time of an Incident, feel that 'restraint' (which encompasses both physical restralnt and, for example, preventing a person leaving a particular place) is the only option to prevent a person from committing an immediate clvil wrong or crminal act; but otherwise expressly confers no powers on police to deprive a person of thelr Ilberty, as the decielon In Sessey v South London &nd Maudsley NHS Trust and Commissioner of Police for the Metropolis ([2011] EWHC 2617 QB) made clear: The relevant thresholds were in any case not engaged on elther of the occasions Ms Ahmed encountered police In her final days. She was presenting as a victim of crlme, albelt a vulnerable not as a person suffering such derangement of mind that she requlred 'iImmediate care and control' which would engage police powers: She therefore was entilled to refuse t0 engage with pollce, and the officers had no power to force themselves upon her: Similarly, whilst the case of Osman v UKe imposes positive obligations on police to take action In certain circumstances where have knowledge of a risk of harm existing, recent case law has Iikewise reaffirmed that pollce owa no general duty of care to members of the public? , nor to victims of crlme"0. There appeared on the face of it at the time of the second vlslt nothing in Ms Ahmed"$ attitude toward police , nor the circumstances in which she was found, t0 engage an immediate duty of care. She had apparently made threats to self ham earller, and there was evidence she had been drinking, which may have led t0 some temporary diminishment of her capacity, but It is clear from the reports of her words and actions on both occasions that she still retained sufficlent 'capacity' t0 pass the test set by the legislation, that Is, t0 understand her situation, and to make decisions about It whlch she did indeed communicate forcefully - to the officers present: was there anythlng In her Immedlate behaviour or surroundlngs to suggest that she was at imminent risk: The option for her to self-refer vla the LAS and A&E to mental health support was available, but not exerclsed: Thus, despite the call which had prompted their attendance, at the time of the second police interactlon with Ms Ahmed, her clearly stated and unequlvocal rejection of the ald offered together with an absence of any observable, immediate Intention to harm herself which might othenwise have mitigated against apparent capacity, makes it dificult t0 see what more offlcers could or should have done within the law, even if they had possessed perfect knowledge of her prevlous hlstory and recent allegation. She was under no obligatlon to engage with the officers If she did not wish to. It follows from this that the question of rapport becomes somewhat moot at the point Ms Ahmed clearly stated her wish to see the police depart: (1998) 20 EHRR 245
0.g. Michael v The Chief Conslable of South Wales Pollce (2015] UKSC 2 10 Brooks v Commissloner of Pollce for the Metropolis and others 2005, [2005] UKHL 24 one, they Nor her

Chief Inspector_ "Police powers of any sort to deal with a Mental Health incident within a private address are limited. The recent Dept of Health/Home Office review of Sections 135 & 136 of the Montal Health Act has resulted In Parliament choosing not to provlde police officers with any specific power by which could support people suffering from Mental Health illnoss within a private dwelling_ This makes voluntary attendance to an A&E & reasonable and viablo alternative for persons In distress; We must remember that people frequently do self admlt to A&E when struggllng with Mental Health, as Mental Health Services are often difficult to access; especlally out of hours: We must also remember that the London Ambulance Service'$ own pathway Into mental health servicos is via an A&E; LAS do not have any direct pathways Into a Mental Health Place of Safety: Concerns re points 4 & 5 above: Information available and shared This brings us to the second strand of the Jury's criticlsm, the lack of information sharilng regardlng Ms Ahmed"s history between police colleagues, and between police and LAS at the scene: Firstly, it Is Important t0 recognise that the totality of infomation avallable t0 police in dealing with vulnerable persons Is greater now than It was In 2014. A key part of this is the Vulnerability Assessment Framework (VAF) introduced to the MPS in January 2014,and rolled out across the following year to the whole frontline officer workforce through regular training days: This is a cognitive tool designed to support our frontline first-responding staff, deliberately designed to extend oficer awareness of potential 'vulnerability' in a subject group, from those narrowly captured within, for example, the terms of the Mental Health Act, to all persons into contact with police_ The intention Is to assist MPS police and staff In recognising any such vulnerability, temporary or permanent; occasioned by any source at the earliest stage of any contact; then t0 maximise opportunities for referral t0 other agencles for early Intervention, to prevent a vulnerable person becoming a victim or suspect at a later 'Vulnerability' is understood therefore to be potentially present in the moment of any initial contact, and arise from pemanent mental or physical impalrments; temporary adverse reactions to prescrlbed medicatlons; substance abuse; mental health issues; or transitory emotional distress. The officer may or may not know what the cause is, and such knowledge may or may not assist in the present situation: Regardless of cause, the emphasis is on recognising effects, and then dealing appropriately with those. The VAF outlines five key factors the 'ABCDE' that must be considered when assessing Indivlduals that pollce have contact with: These are:- Appearance Behaviour Communicationlcapacity pgaln: they coming stage. may

Danger (caused or exposed to) Environmentlcircumstances_ If three or more of these factors glve cause for concem, conslderation using professional judgment should then be given to whether an appropriate protective safeguarding pathway is requlred. Where three out of the five VAF areas are Identified, then a Merlln' database entry for a 'Vulnerable Adult' must also be created as a mInlmum, and a safeguarding response documented: These details must also be captured on the crime recording syetem 'CRIS' , Ifa crime is alleged. The officer will also be encouraged t0 adopt a 'CARES"11 approach at the scene: "C ontain the situation rather than restrain. A pproach within vlew of person: Avoid approachlng from behlnd. Reduce distractions helmet off; turn radio down; one officer talking: Explain what you are (simple language) and Iisten to the person: S low down your actions and give the person more space. Seek the help of a relative or Carer: It Is also necessary to recognise however; that adults with evident capacity are entilled to make 'lifestyle choices' wlthout state interference, even If these are, objectively considered, bad ones. Considered in Isolation, individual instances of such behaviour may or may not warrant the creatlon of a 'Vulnerable Adult' entry on the] Idatabase (officers always have discretion to record an entry, even if less than three of the 'ABCDE' factors are present at a slngle encounter; If in thelr professlonal opinion, an entry is warranted:) The intention is that over pollce wlll; through thls mechanism , naturally build a searchable 'corporate memory' of contacts with vulnerable persons, or persons whose vulnerable behaviours have brought them into contact with the police. This history also then provides the basis for tracking the diversion of such people t0 organisations better equipped t0 meet thelr needs than the police. These optlons, however are for the most part 'slow time' actlons, that Is, for after-the-event consideration; within the secondary stages of Investigation. However; at the time of an encounter; (his type of In-depth Intellilgence, whllst accesslble directly to any officer making their own enquiry (in preparation for a pre-planned visit; for example, or, as DST Idemonstrated, in undertaking his risk assessment) would not have been automatically provided to first responders. These officers are tasked In 'fast time' In response to calls recelved by the MPS Command and Control Center, MetCC. In both of the two final encounters with Ms Ahmed; it was unifomed patrol officer first responders who were initially seeking to bulld rapport with her; rellant In the first instance on the necessarily more limited 'deployment intelligence' provided for officers in their role. As Chief Inspector Professional Standards Champion at Met CC explains: "The provlslon of Intelllgence and the Service Level Agreement that had boen agreed with [Met Pollce] business groups at that tlme was that [MetCC] would provide 'deployment intelligence only' that is, primarily officer safety information, unless the Source: Phase 1 Ofiicer Safety Training Lesson Plan; 'Safety In Mind' Mental Health DVD input, created
10.02.15 10 dolng time,

call concerned absent' chlldren or a limited number of other pre-Identlfied 'hlgh risk' categorles of calls, for example, firearms or extended response domestic abuse calls which attract an enhanced level of background intelligence enquiries: In 2015 this process was reviewed &s part of the 'New Way of Working' and was cemented within that document: Between August and October 2015 1300 Met CC staff were briefed on the provision of 'deployment intelligence and aS a result; in excess of40,000 more deploymonts havo sinca been made where ofilcers have received actionable intelligence before Time Of Arrival on scene. This is &n improvement in the timeliness of our provision of deployment intelligence, but it Is Important t0 understand the constraints under which this Tfast time' Intelligence research must take place: For the Information t0 be most useful; it must be obtained and made avallable to the respondilng ofilcers between the tlme of the recelpt of the call, &nd the arrival of officers on scene at it We aim to arrive on scene at an 'Immediate' (I- grade) call within 15 minutes 90% Of tha time: We aim for an S ('Soon') grade response time of wlthln 80 minutes 90% of the tlme. To cope with the volume of emergency calls received within the Iimits of staff available to fleld those calls, our call handlers therefore must deal wlth each call wlthln an average of 371 seconds: In November 2014 Intelligence for all Computer Alded Despatch reports (CADs; the typed location and incident-type records used to document assigned units and capture outcomes) was provided by a centralised Intelllgence function spllt between Lambeth and Bow MetCC centres: This Is now based entlrely at MetCC Lambeth. Intelligence checks are conducted on all / and S grade calls and added to the working CADs; If relevant the despatcher will then alert officers &t the scene. MetCC operators are tralned to provide deployment intelligence for Offlcer Safety issues only: At the time of this incident; the information that Ms Ahmed had called the Ilous would have been avallable to the despatcher because the callers number and other detalls would have been hlghlighted on the CAD screen. If the despatcher had clicked on one of the highlighted headings; the previous days' deployment would have been vlsible t0 them: It would be best practice for this to be done, but it is not mandatory, nor alweys practicable. As Ms Ahmed did not show any known offlcer safety concerns the previous day's call, despite thls informatlon being avallable on other MPS Intelligence systems relating t0 visits on other earlier ccasions; no additional Intelligence would have been provided via this route. Fast-time Intelligence checks however are now conducted using the through which @ single query will search the separate Idatabases: The search Is conducted using data Input by the operator, drop down menu for ofiicer safety risk and & key words search relating to olficer safety Oficers use the mnemonic 0 structure the searches: 'Index and T- Telephone numbers: PNC checks are also done separalely; If names and datos of blrth are known: Desplte 'qulck overvlew' thls search provides, Ilmltations wlthln our current search functionality means that the only way to be sure of gathering all relevant data on & day prer from the

venue, victims, suspects etcetera Is t0 read each of potentlally very many Information reports, Police National Computer records, Merlin entries, Crime reports, custody records and so on in detail Since each one of those record types could run t0 many pages, this task Is clearly not capable of being undertaken within the minutes or seconds available to assist our flrst responders: Given these time strictures It remains beyond the current capability and capacity of MetCC SCO37 t0 provide a fallsafe , all encompassing intelligence functlon for first responding officers. The expectation therefore must be that the focus of 'deployment intelligence' remains high risk officer safety intelligence. Officers at the scene of an Incident must continue to conduct their own dynamic rlsk assessments, investigate the incident and apply professional judgement to thelr decision making process This mak then Include them seeking 'further &nd better particulars' through local colleagues conducting more detailed research on our systems, either via radio from the scene t0 their local 'Grip & Pace' borough intelligence support If avallable (though not all 'Grip & Pace' intelligence functions are staffed 24/7); or later, In person, when time and clrcumstances permit; In short; to answer the concem regarding information sharing; at the time of the first Incident, the initial responding officers had no automatic method of accessing the historical information available to an In-depth manual interrogation of our systems; and officers at the second call would Ilkewise not have been automatically alerted t0 the existence of the call the day before. In both cases the attending officers would have had to initiate their own requests, If they felt needed further background Information: It was not practicable then, nor Is It now, to provide full dlsclosure to Initial attending ofilcers of all possible intelligence relevant to the venues and partles they deal with, which may be held within the greater police Intelligence structure, withln the time frame of an emergency response. Moreover; the question must agaln be consldered: even K this infommation had been available, what practical difference could it have made t0 the oficers handling of the incident; given Ms Ahmed'$ clearly stated rejection on both occasions of police Involvement? Steps were still being taken t0 progress the enquiry from the suspect side; had Ms Ahmed Ilved, further low-key overtures by a SOIT officer would have doubtless been made to engage with her; outside of the inherent drama and potential conflict of an emergency unifomed response. Unfortunately; this was not to be. In conclusion Faced with the (all too common) dilemmas ralsed by 'crisls' Interactions with variously vulnerable people, the lesson the MPS has taken from such cases in our training and support of front line officers is to foreground a victim-centered approach, as discussed above. In sum, this means: Ensuring that our officers and staff receive appropriate training and support In engaging with vulnerable persons (e.g: VAF, CARES) Ensuring our frontllne offlcers and staff recelve appropriate advlce on Initlal reporting of sexual offences via 24/7 intranet access to best practice guldes & expert on-call specialists 12 they

Revlewing our protocols for the deployment of Sexual Offence trained speclallsts Reviewing the management and sharing of Infomation from our call handlers to our response officers; as in the 'New of Working' discussed above; and between the MPS and our partner agencies, via such initiatives as the MPSILAS Memorandum of Understanding; and other mult-agency fora: The concerns raised here regarding police interaction with Ms Ahmed are also closely echoed In the thematic groupings of the MPS response to the Angiollni Review, already under way at the time of this incident; which similarly addresses: The service provided to victims Supporting our practitioners Accountability and continuous Improvement Legislative change Common to Dame Angiolini's critique, our response to it, and the Joint National Rape Action Plan Is the recognition that the past several years has seen some success by the Police and the Crown Prosecution Service nationally in encouraging the reporting of sexual assault. In the same perlod London has also seen Increasing dlverslty in and growth of Its' population: The consequence of these elements combined Is a concomitant increase in the workload of the speclalist 'Sapphire' units tasked with investigating sexual offences, which are amongst the most technically demanding officers deal as the Angiolini review notes: "With a population in excess of 8 million, London's size and geography make unique demands on policing: It is also by far the most ethnically and culturally diverse clty In the Unlited Kingdom, a diversity that Is reflected In the profile of complainants and suspects who the police encounter when Investigating cases of rape. The rise In the number of reports of rape year on year present the police with an enormous challenge In London, especially given the complexltles of Investigating rape, a challenge which Is not made any easler by overstretched resources [Review , para 5, p. 10] Commlssloner Slr Bemard Hogan-Howe acknowledges that these pressures have required a reconsideration of the police response, including within the 'Sapphire' units, and he has committed to providing the resources to make this possible: "accept that there Is an acute need for Increased capacity and capabllity on Sapphire teams and | will ensure that the future structure and resourcing model is deslgned to meet the demands of increased reporting levels and promotes & worklng environment that Is carlng and supportive of Its offlcers Linked In t0 thls Is my commitment to invest in training to ensure that flrst responders and investigators are equlpped with the tools need to perform their roles to the highest standard: [Response, P.10] There Is also acceptance that the police cannot undertake this work alone; a large number of the recommendations In the Angiolini and National Plan recommendations address Improved criminal justice practices, to be led by the Crown Prosecution Service: There is also a 13 Way' with, the they

recognitlon at initial Investigatlon level of the value of the 'Haven' Sexual Assault Roferral Centres run jointly by the MPS with the NHS. The aspiration here is t0 expand and enhance the role of Havens in their key tasks of capturing best early evidence, and in supporting victims. It sadly must remain unknown what level of rapport our speclalist sexual offence Investlgators might have been able to achieve with Ms Ahmed, had she lived to engage with them: We must acknowledge however that even with an enhanced fast time intelligence capability; and our Improved training of frontline officers In dealing with vulnerable persons, we are still bound by law to respect the autonomy of any innocent member of the publlc demonstrating sufficient capacity to declde not to engage with us, even If they have previously sought our aid, Through training and technology we can maximise the Iikelihood that rapport will be establlshed and a working alllance established, and even; where other sources of evldence exist; and it Is in the publlc Interest to do s0, pursue 'victimless' prosecutions. But we can never guarantee that rapport will be established with all victims in all circumstances: