Dear Coroner, Thanks for your report (dated in error as 15th August 2019) to the College of Policing under paragraph 7, Schedule 5, of the Coroners' and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 regarding the tragic death of Dane Lee Pearson: The College of Policing has responsibilities in relation to, among other things, developing national guidance: National guidance is written into Authorised Professional Practice (APP) APP is generally made available on the publically accessible College website_ A small number of APPs have restricted content and are not publically available, but that is not the case with regard to matters raised in your report: The circumstances described in the report raise two issues_ Firstly, the process followed by the police in issuing Child Abduction Warning Notice (CAWN) does not take sufficient account of the possibility that a person receiving a CAWN might be particularly vulnerable and, therefore, a suicide risk: Your report indicates that Mr Pearson did not recognise the description of the events that led up to the issue of the CAWN: Whilst the CAWN guidance is clear about the need to identify the child subject of the notice, it is not clear about the need to describe the behaviour giving rise to the CAWN: The College is about to release updated APP on issuing CAWNs and this will reflect the need to out a risk assessment There is existing guidance on suicide prevention in our Mental Health APP. The new CAWNs APP will Iink to that document s0 that those dealing with these issues are easily able to access the best advice. It will also make clear that a description of the events leading up to the issue of the CAWN must be carefully explained to the recipient: The second issue relates to updating suspects when investigations concerning them have been concluded: The national policing lead who has operational responsibility for overseeing implementation of practice in relation to police bail has recently issued advice to forces regarding 'release under investigation' _ i.e. those cases where a suspect is not subject to police pre-charge bail, but is released police custody without conditions whilst an investigation continues. The advice is clear about the necessity to keep suspects updated about the progress of investigations. College ol Palicing Limitedb company registeredin England wd Wales wlth registcred numbcr 8235199 and VAT reglstcred numbct 152023949 Qur rogistered allko k at College ot Polklng Lintitod, Laxnington Road Ryton-on Dunsmor Coventry Cva JEN otna aN the the cary from

The guidance contained in College Investigations APP will be updated to reflect the requirement to keep both victims and suspects updated on progress of cases, including informing a suspect when an investigation about them has been concluded: The measures have described above address the issues raised in your report and am grateful to have opportunity to take steps to improve police practice in this area Yours sincerely, ul~ David Tucker Faculty Lead Crime & Criminal Justice the

2 Marsham Street; London SWIP 4DF Home Office wwwhomeoffice gov uk Alison Mutch OBE HM Senior Coroner Manchester South Coroners Court Mount Tabor Street Stockport SKI 3 AG 25 June 2019 Dear Ms Mutch Death of Dane Lee Pearson Thank you for your letter of 15 February to the Home Secretary regarding the death of Mr Dane Lee Pearson: am responding as the Minister for Crime, Safeguarding and Vulnerability. sincerely apologise for the delay in my reply: was to read about the circumstances of Mr Pearson's death. Ensuring public safety is a key element of policing and any death associated with contact with the police is something know police officers feel keenly: The matters of concem that you ralsed are primarily operational and procedural matters for the police who, understand, will be responding to you separately: However; wanted to let you know of changes made to slatutory guidance since 2017 which hope will help to address some of your concerns regarding steps to better identify and protect the rights of vulnerable individuals. The treatment of those arrested and under investigation for alleged criminal offences is governed by Part 4 of Police and Criminal Evidence Act 1984 (PACE) and by PACE Code of Practice C. While, at the time of Mr Pearson's contact with the police in 2017 , there was existing guidance in place relating t0 the handling of investigations and the treatment of potentially vulnerable individuals, this has subsequently been strengthened. As part of ongoing reviews of PACE Codes, a revised version of Code C came into effect on 31 July 2018 superseding that in place in 2017 . It introduced a new requirement to take proactive steps to identify and record any factors which provide any reason to suspect that a person may be vulnerable and may require help and somy the

support from an appropriate adult: It also requires a record of those factors to be made available to police officers, police staff and others who are required or entitled to communicate with the individual concemed, So that - may be taken Into account in such communications: The changes reflected existing good operational police practice, the work of the Home Office chaired Working Group on Vulnerable People and responses to the consultation on changes to the Code: We expect that the present requirements will help to prevent future deaths arising in similar circumstances t0 Mr Pearson More broadly the Home Office will continue to work closely with the police t0 ensure that have access to necessary information and support when dealing with those with mental health issues and t0 ensure that, collectively, the response to such individuals continues to improve_ Vuku Ktx Victoria Atkins MP they ' they'

GREATER MANCHESTER E"R POLICE Ian Hopkins QPM, MBA Chief Constable HM Senior Coroner Ms Alison Mutch OBE Coroner's Court Mount Tabor Street Stockport SK1 3AG Your reference: 8949/CLB 25 March 2019 Dear Ms Mutch Re: Regulation 28 Report following the Inquest touching upon the death of Dane Pearson Thank you for your report sent by letter dated the 15 February 2019 in respect of Mr Dane Pearson (deceased) and pursuant to Regulations 28 and 29 of The Coroners (Investigalions) Regulations 2013 and paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 Having carefully considered your report and the matters therein, reply to concerns raised as follows: 1; In this case the_CAWN_had beenissued on limited evidence_particularly_regarding identilication Inaddilion ithad_ been issued_many monlhs after_the_allegation and_after_the authorsation The_inquest was told that the process had not_been_followed_relating_to limeliness There was nO documentation in existence explaining the rationale for the issuing of the CAWN On the 14 June 2017 a child who had been missing from home was interviewed when she was located by police. From this missing from home retumn interview intelligence was placed onto the police OPUS system; The information received stated Ihat Mr Pearson had allowed an 18 year old male into his flat, who subsequently invited three females under the age of 15 years into Mr Pearson's flat. One of the females was kissing and hugging the 18 year old male: Concerns were raised as to why a 3Oyr old male was allowing vulnerable teenage girls into his flat; Following this information received by the police , the Child Sex Exploitation (CSE) team in Operation Phoenix at Tameside discussed the intelligence during a govemance meeting on 3 July 2017 and again in August 2017 where there was a task generated to serve Child Abduction Warning Notice (CAWN) on Mr Pearson. Fae Ihe being the

By the time the notice was able to be served on Mr Pearson on the 30 November; some five months had elapsed since the intelligence about the girls being in his flat had been first received: Mr Pearson was not shown photographs of the girls and Mr Pearson refused to sign notice, stating that he did not know or recognise the girls' names. This was not in accordance with policy and may have impacted Mr Pearson negatively due to elapsed time and lack of opportunity to reconcile pertinent details about the females referred to in the CAWN: Point two; below, addresses what GMP are to ensure policy and processes lead to more effective management of the CAWN procedure: 2: Inissuing_the CAWN there was no evidence thathis_known vulnerabilityhad been taken _into account Arisk_assessment_ had not_beencaried out Inthis_case; officers_attended at_his home address and served the CAWN on him: He refused t0_sign it on the basis; he_had no knowledge of_it or the_circumstances behind it Itwas leit with with no clarfication about what ifany steps he could take_in relation toit The_inguest heard evidence_that he was deeply worried about itand the impact on his life Greater Manchester Police (GMP) have instructed all staff across the force t0 ensure that the correct process regarding identification and timeliness is adhered to. The College of Policing national policy has been reviewed alongside GMPs policy and a new 2019 policy and procedure document written which details the role responsibility of each officer involved in the issuing of a CAWN nolice. The CAWN notices will be managed within each district in the intelligence Hub for consistency: This document and the new process within districts will ensure that staff continue t0 comply with their responsibilities regarding the CAWN process as below,
1) The current service forms include the Inspector'$ signature and comments t0 ensure that officers follow the correct procedure and that there is space t0 record everything applicable
2) out a risk assessment prior to the service of a CAWN t0 ensure that consideration is given to suspect's history; particularly relating to any intelligence about vulnerability or threats, and include the outcome of the risk assessment in the CAWN service forms:
3) Update the Force Intelligence Systems with relevant information about the CAWN and schedule monthly reviews t0 monitor that notices have been served appropriately:
4) Update the policy with guidance on what to do when attempts t0 serve a CAWN fail.
5) Establish an ongoing audit process for checking the 48-hour time limit and six-month reviews are adhered to_ the the doing him and Carry

As part of the risk assessment referred t0 above in point 2 the rationale for the CAWN must be fully documented and the risk assessment must include the potential impact of service of notice on that suspect: Officers take copy with them and leave copy with the suspect with their contact details allowing them to contact the officer in the case at a later time should there be a need to obtain clarification or further guidance on compliance with the notice: 3: The_inquest_heard_that_QPUS _the_Police_system did not_appear_to have_been_correctly updated with markers to flag_his vulnerability _ It is acknowledged in this case that Mr Pearson did not have any markers associated with vulnerability: GMP were aware of information, as referenced in crime 267721Y/17, that Mr Pearson suffered from mental heallh issues, namely depression: This crime was ultimately finalised due to Mr Pearson being reported to have suffered an episode related to his mental health or drugs which negated the likelihood of criminal intent Following Mr Pearson's contact with officers and staff, a marker could have been placed o his nominal record (a record held on GMP's OPUS computer system) lo indicate mental health issues, this is referred to as a "MN' waring marker: A fomm known as a "form 575A" is needed to add a WM to the Police National Computer: The purpose of this marker is to warn officers and staff that an individual suffers from mental health issues. This information would enable officers to understand the individual may potential present a risk to themselves, the public and the ofiicer dealing: The officer or staff member could then tailor their approach appropriately where necessary: There is not currently, a force policy or guidance document on Waming Markers. The decision whether (0 add Warning Marker to an indivduals nominal profile (OPUS profile) depends solely on the professional judgement of individual officers and staff. Police Officer or Support Staff member having contact with an individual directly (at an incident or in custody for example) or indirectly (such as receiving report or processing informationlintelligence about them) can update their profile with WM (a markerthat is nationally recognised and applicable to both GMP systems and the PNC) of the Force Intelligence Bureau (FIB) is (asked with GMP's first Force policy and guidance document on the use of WM; This be completed the Any writing will

when several factors can be fully considered. This includes seeing the capability of our new iOPS system and awaiting mandatory reform requirements from the Anthony Grainger Public inquiry (which is likely to include necessary actions required around warning markers) Part of this policy will be that officers and staff are actively encouraged to place appropriate warning markers on police records to help manage risk going forward. As a Force; we are currently in the process of implementing a new; integrated operating system which will replace many of our existing systems. has worked closely alongside the iOPS team to ensure that all requirements for safely managing intelligence are met GMP have provided the following as essential functions in relation to markers;
1) The ability t0 add, update, review and remove WM:
2) Automatic notifications to officers to complete mandatory reviews of WM:
3) Mandatory recording of the provenance of WM and link back to more detailed information rational:
4) Mandatory recording of the officer updating and the timeldate.
5) There will be a detailed warning message to be displayed within the system. This warns officers accessing information that they must not act on WM without reviewing the information that sits behind it; "Warningl This system ad the data within are restricted to authorised users for appropriate policing purposes: Unauthorised access could constitute an offence under the computer Misuse Act and be considered as a breach in Data Protection. Users are reminded to ensure that any intelligence or personal information obtained from this system is still relevant before acting upon it. Users are asked to pay particular attention to and Warning Markers and we encourage users t0 review information behind the marker wherever possible This warning message has been implemented and can be seen in the test system: am confident that will continue to make improvements around OUr usage of warning markers in both the short and long term iOPS senior leadership team reassure me these requirements will all be in place in the new system in time for go-live (no set date has been confirmed yet): 4: The inquest was told that hewas placed under investigation for a suspected attempt burglary and possession of an offensive weapon Adecision was taken bY the OIC and his sergeant that it should be NFAD. Thedecision was not communicated to _Mr Pearson The_ofiicer had not key Flags the

followed the_process [or notification ol decisions_to_those under investigation_Asa result_at the time of his death he_believed he may be_charged with a criminal ffence: On the 3 April 2017 the Policing and Crime Act 2017 made changes to (he Police and Criminal Evidence Act (PACE) 1984 and the Bail Act 1976, which mean that there is now a presumption that suspects who are released without charge from police detention will not be released On bail: This follows an increasing recognition of the effect on suspects of sometimes lengthy periods on bail and the associated disadvantages, particularly where no further action is taken: In cases where police bail is considered necessary and proportionate, the authority levels, criteria and strict timescales have been drafted to ensure the fair treatment of suspects _ In the majority of cases police bail will only be lawful if conditions need to be imposed upon suspect in accordance with PACE 1984 Section 30A subsection 38. A suspect will be released under investigation (RUI) unless the criteria for the imposition of bail and associated conditions are met There is no national legislation, policy Or guidance on the appropriate timescales or governance for RUI. In GMP the management of RUIs is difficult due to the number of different IT systems which are not integrated and do not talk to each other: When a suspect is released RUI the ICIS custody record is updated and PNC is updated from this system: All suspects will be shown RUI until the ICIS custody record is closed or changed from RUI and PNC updated: A notice is automatically sent to the suspect when this been done_ Officers investigating crimes (OICs) use the OPUS crime management system to record actions and activity in relalion to the investigation of crime including the status of the suspect The OPUS crime management system does not update ICIS custody record, PNC or cause notification to be sent to the suspect If the suspect is charged then there are obvious avenues by which the suspect is informed but this is not the case for a NFA disposal where the suspect will only be formally notified when the ICIS record is updated or the OIC informs the suspect: Prior to 2018 GMP open RUI records within GMP had been increasing each such that more were being opened than closed. Since July 2018 a number of activities have been carried out with the aim of reversing this trend and putting in place measures to effectively manage RUI in the future This activity had the effect of steadying the increasing number of outstanding RUI: police police has the July day has

The activity has included: The central criminal justice team provides detailed information to local districts to assist Ihem in the management and governance of RUls Govemance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining Up crime management and RUI activity: The bail and RUI policy has been revised to provide on the roles and responsibilities of officers and local leaders in the management of RUI, Targeted work, both local and centrally, to close outstanding RUI records. Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing suspect Local bail managers have introduced trackers t0 manage RUIs in (he same way as pre- charge bail is managed: RUIs are discussed regularly at local crime governance meetings Central CJ team are dip sampling records regularly to monitor compliance and highlight cases As it stands, without changes in our IT systems (the systems will not be upgraded due to the pending the iOPS implementation) , it is the responsibility of the OIC to close the ICIS record and inform the suspect when a decision to finalise the crime and take no further action has been reached: Briefings have been disseminated to front-line officers to remind them of their responsibility for RUI management; the closure of ICIS records and informing the suspect of the outcome_