METROPOLITAN POLICE PROFESSIONALISM HQ Miss Sarah Ormond-Walshe, Matthew Horne Senior Coroner, Deputy Assistant Commissioner South London Coroner' $ Office, 6th Floor 2nd Floor, Davis House_ New Scotland Yard Robert Street, Victoria Embankment Croydon, London CRO 100 SWIA 2JL Coroner' $ Clerk: Email: Tel: 020 7230 1417 fice Your ref: 01/c0/19/000249 8 8 MAR 2019 ref: IX/83/17/ 1902_23 Date: 14th March 2019 Decc (liss Orkod _ Coodeht am Deputy Assistant Commissioner Professionalism in the Metropolitan Police Service (MPS) write in response to your Regulation 28 Report to Prevent Future Deaths dated 15t January 2019- Your report was sent following the conclusion of the inquest into the death of Ms Catherine Anne Horton: In drafting this response the relevant subiect matter experts have been consulted, principally: Detective Superintendent South Area BCU Safeguarding; Detective Chief Inspector Safeguarding (Transformation); Assistant Commissioner Frontline Policing and Chief Superintendent Transformation. Response to Matter of Concern: There were multiple failures in the days leading up to Ms Horton's death. During the evidence it was made clear that a mistake was made in relation to missing person investigation relating to the deceased (before a Safe and Well check had been undertaken) This occurred at a time when staffing was low ad the expectations of the Officer or Officers working on particular days was well above what was achievable. Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries: strongly suspect that resources are stretched in every department of the MPS. However; the persons' unit may not be seen as readily as other departments as life-saving department: Of course it is because of the vulnerable nature of the persons missing and | am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton's death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work am asking the MPS to ensure the missing persons unit has sufficient officers working in it at busy times, So as to make their job achievable, and t0 minimise the likelihood of mistakes happening: Our closing missing

The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017 The MPS has now implemented programme to incorporate two boroughs into twelve Basic Command Units (BCUs) , providing resilience and consistency across London to the MPS meet its financial and operational challenges The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment t0 what is acknowledged as an area of risk Under the delivery of this new policing model for London, each BCU has established a MPU that is resourced according to local demand: Each MPU works to a set of minimum standards of operational procedure , staffing levels , skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues_ The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular: MPUs are located within a new BCU Safeguarding Hub, which has combined policing units that deal with the most vulnerable together under a single command structure. This allows the local safeguarding senior officer, who is a Detective Chief Inspector rank in the Safeguarding Hub, to take a holistic approach to short and longer-term risk management The local Duty Detective Inspector has the flexibility to increase Officer numbers in the MPU at times of high demand due to the flexibility of the new BCU model. Safeguarding hubs also deal with mental health, child sexual exploitation and referrals from local authority adult and child safeguarding services The MPS has invested significantly in safeguarding focused police officer posts as part of the new BCU model, which has resulted in an increase of dedicated MPU officers. The MPUs are now integrated with local command and control functions via a local operations room in each BCU that monitors live and incoming risk at all times: new missing person who comes to the notice of police will continue to be risk assessed and monitored by the emergency response team Duty Inspector: Any high-risk missing person will immediately be passed to the Safeguarding MPU under the direction of a Detective Inspector who will utilise all relevant and available resources to ensure priority actions are addressed. Safeguarding investigation teams across London are resourced 24 hours day following the implementation of corporate shift pattern: This delivers greater operational resilience to the Duty Inspector overnight to ensure that crucial lines of enquiry can be conducted with the required urgency: Following the implementation of BCUs, led by the Assistant Commissioner for Frontline the Deputy Assistant Commissioner for Local Policing will conduct a three month review of their progress; this provides the opportunity to check that all the elements of the BCU including MPUs are working effectively. This will be followed by a full review (June to September 2019) and recommendations will be provided on how to further improve the model taking into account pressures that have been experienced and address any risks or issues that have been identified The MPS has reviewed and updated its policies and standard operating procedures for on- going risk-assessments, investigations and interviews with returning missing people_ Interviews with returned or found missing people are aimed at prevention of further missing episodes: Information that could prevent the person going missing again, along with any other information affecting their welfare, is disseminated to our policing and partner agencies, which allows for early intervention_ thirty help Any Policing;

Investigator toolkits have been updated and are now readily available via response officers' standard issue mobile-devices Further advice and support is available from safeguarding officer attached to every BCU Operations Room, who will have had the safeguarding induction course and will be substantive detectives. All officers posted to MPUs must attend mandatory week-long training course that was redesigned in 2018 and is now delivered to officers in every BCU. Three day bespoke training is also being delivered to BCU Duty Inspectors South Area (SN) BCU incorporates the boroughs of Croydon, Sutton and Bromley: The South Area MPU has had an uplift of officers with a plan to increase staffing levels further in the near future. High risk missing person cases should attract a BCU response and a senior detective within the Safeguarding Hub will lead the investigation There are currently some challenges regarding the investigation of low and medium graded missing person reports before reach the MPU, however this is now being addressed as a matter of urgency: In Conclusion Since 2017 the MPS has undergone a significant restructure with the implementation of a BCU model_ BCUs now have dedicated Safeguarding Hubs staffed by trained officers and a chain of command that addresses the changing demands of each BCU in order to manage the to day risks. The MPS has invested in additional staff in MPUs and provided access to 24 hour support to afford the necessary flexibility and resilience to the investigation of missing persons trust this provides the reassurance that the MPS has considered the points you have raised, and that we have moved promptly to make such improvements_ Please do not hesitate to contact me if can be of further assistance_