Dear Ms Hassell,

I am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (MPS). I write in response to your Regulation 28 Report to Prevent Future Deaths dated 29th October 2018. Your report was sent following the conclusion of the inquest into the death of Ms Rosario Cordero- Sanz.

In drafting our response we have consulted with the relevant subject matter experts, principally: Inspector , Citizens in Policing Metropolitan Special Constabulary (MSC) - Continuous Policing Improvement, Detective Constable , Directorate of Professional Standards’ Specialist Investigations; , Head of Support Met Command & Control (Met CC) and Inspector , Central East Borough Command Unit (CE BCU).

Response to Matters of Concern

1. MPS special police officers are not issued with tablets as regular officers are, yet the three on duty who attended on Friday night/ Saturday morning were given one of the police vans that is not equipped with an on board computer. This meant that they could not check details on police computer systems themselves. Instead, they had to radio for assistance.

In September 2018, the MPS committed to the purchase and issuing of one hundred tablet devices, to be used as pool devices for MSC officers. The allocation of tablets across the MPS has been designated according to budgetary and operational demands. The roll out of these devices was completed in November 2018 and they have now been evenly distributed within frontline policing across the footprint of the MPS. Data usage is currently being collated, with the intention of increasing the pool size in the future. It is to be highlighted that the use of a tablet in an operational situation may benefit officers, however this is a relatively recent addition and officers are expected to use their police radios where tablets are not available. We have addressed this issue with the officers directly.

Richard Martin Deputy Assistant Commissioner 6th Floor New Scotland Yard Victoria Embankment London SW1A 2JL

Email: R

Tel: 020 7230 1417

Your ref: Our ref: IX/52/18 & 1901_02

Date: 22nd January 2019

Ms Mary Hassell, Senior Coroner, Inner North London St Pancras Coroner’s Court, Camley Street, London, N1C 4PP

Tel.: 020 7974 4545

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2. In addition, the jury heard as follows.

 The three police officers did not appear to have an in depth understanding of the misper process. On their initial foundation course, all MSC officers receive training on how to deal with a missing person and are expected to be conversant with changes in legislation and policy. The MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, or indeed any police officer, is unsure of how to deal with an incident they should seek supervisory advice at the scene. In light of this incident, all MSC coordinators who are experienced police constables supporting the MSC, have been tasked to review the support of MSC practical learning.

The failures identified within this matter of concern represent individual failings which have been addressed directly with the officers concerned.

 They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.

S136 Mental Health Act would not have assisted the MSC officers in this particular situation because it does not apply to a person inside a private dwelling.

In general terms the MPS response to incidents involving people with mental illness has evolved significantly over the last few years and continues to do so. We are committed to continual training and partnership working which has been incorporated into the annual officer safety training programme for all officers, including MSC. MSC officers are provided with mental health training in their foundation course which includes awareness of signs, symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, which includes training, awareness and support for all officers. MSC are also incorporated into the Home Office funded MIND Blue Light Champion Programme, whereby selected MSC officers, alongside regular officers, are trained as mental health champions. The role of these champions is to raise awareness of mental health across the wider organisation, both in a personal and professional capacity.

 They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.

Language Line can be accessed via police Airwave radios at any time and full instructions on how to access this service is readily available on the MPS intranet. Instructions on how to use this and its benefits have been recirculated to the MSC via the duty sheet messaging system. The failures identified within this matter of concern represent individual failings which have been addressed directly with the officers concerned.

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 Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.

It has been established that the MSC officers who attended the address were not provided with the full details of the call. The informants whom they spoke to did not indicate that Ms Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained more information at the scene utilising Language Line they may have altered their risk assessment and seen her in person. Whilst the suggested considerations have merit, we would not seek to make them mandatory actions as they may not be appropriate or practicable in all circumstances. Had the MSC officers known Ms Cordero-Sanz was a high risk missing person, MPS policy would have required them to physically see her and ensure she was safe and of no danger to herself or others.

The failure to physically see Ms Cordero-Sanz is a collective failing by the MSC officers and has been addressed as previously detailed.

 Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.

The MSC officers did not consider that an ambulance was necessary based on the limited amount of information they had when dealing with the incident. The initial CAD operator (call receipt) requested an ambulance attend, based on the information given to him by the informant over the telephone and by asking relevant questions. The MSC officers did not have access to the CAD and were unaware an ambulance had been requested. They were told at the scene that she was safe and well inside the premises with friends and her family were en route.

 I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?

The MPS has supported the dissemination of the learning opportunities presented by your report and is reviewing training in the context of both the MSC and the regular service. The MPS identifies that an aspiration to patrol MSC officers with regular officers on a regular basis would be unachievable due to competing demands, as well as MSC availability. As a direct result of this incident, CE BCU has put processes in place to ensure that MSC officers are briefed and debriefed at the start and end of their tours of duty and have supervisory support throughout. Commander Musker, the lead for frontline policing, has directed that this process be implemented across all other BCUs.

3. The three special police officers who attended late that Friday evening / early Saturday morning were described as kind, and clearly demonstrated concern, but ultimately they did not know that they were dealing with a high risk missing person. Without tablets or a mobile data terminal, they had no means of checking this themselves.

The jury found that the special sergeant and the CAD operator did not actively listen to one another. This meant that the Merlin system was not checked again after officers had

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obtained Ms Cordero-Sanz’s full name, missing the opportunity to match her details with those reported earlier and to identify her as a high risk misper.

The issue relating to availability of tablets and mobile data terminals has been addressed in matter of concern 1.

The failures identified within this matter of concern represent individual failings, which have been addressed directly with the officers/staff concerned. The opportunity was missed to provide the CAD operator with Ms Cordero-Sanz’s full name as the MSC officers at the scene assumed the CAD operator already had this information. In relation to checking the Merlin system, this will be dealt with under matter of concern 4. The expectation is that officers update the CAD fully once details have been obtained at the scene. The MPS accepts that if the MSC officers had access to a tablet on the night, then they could have carried out their own PNC check on the full name they had written down, which in turn would have informed them Ms Cordero-Sanz was a high risk missing person, however a PNC check should still have been carried out on their MPS Airwave radio.

4. There was not a full understanding among the CAD operators of how to search with only part of a name e.g. CORDERO* as a wild card. This seems a significant omission in the understanding of those fulfilling that role.

Two issues arise from this matter of concern, which are detailed below:

 Merlin has limited capacity to perform ‘wild card’ searches. It has no Boolean capability and cannot perform searches of terms within a certain distance of other terms; it is the system, and not the operators, that is limited in this way. More importantly, no wild card searches could have assisted in this case, since the CAD operator (call receipt) only had the first name to search on and therefore had no reason to contemplate a wild card search. The spelling was provided phonetically and the CAD operator could not have known that it was wrongly spelled. In any event, it would not have been reasonable to search for ‘Rosareo’ multiple times with every letter in turn replaced with an *.

 The second CAD operator’s (call despatch) mistake was not related to wild card searches either. His error was not to check Ms Cordero-Sanz’s name and its phonetic spelling with the officers at the scene. However it is acknowledged that CAD operators have numerous demands placed on them at any one time and are generally dealing with multiple calls. This was a failure of communication and active listening, and has been dealt with by way of local learning for the MSC officers and the second CAD operator.

Conclusion

The MPS believe there was not one defining moment but rather a series of errors or omissions that were contributing factors towards not identifying Ms Cordero-Sanz as a high risk missing person.

As detailed within this response, the responsibilities and actions expected of officers in relation to many of the matters of concern raised are all covered by a framework of guidelines, policy or legislation. They are also provided in foundation training and refresher training. The errors and omissions identified within your report mostly represent individual failings or lack of understanding.

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All officers have a duty to maintain their professional knowledge under the College of Policing’s Code of Ethics (Duties and Responsibilities); training and reference materials are readily available to support officers and staff.

Following the inquest, these matters were dealt with under a gold group governance structure, chaired by Commander Musker, to address and implement a plan of action both at CE BCU and across all other BCUs regarding the identified issues. The critical need to have effective ongoing supervision for MSC officers was recognised and implemented as part of the action plan. This process is influenced by learning from day to day operations and vulnerabilities highlighted from investigations including inquests.