Serial offenders could continue being missed by the Metropolitan Police due to the force’s failure to carry out the ‘most basic research’ when investigating sudden deaths – often ‘relying on luck’ to identify links between cases, says a new report.
The stark warning follows an inspection of the force by His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS), which has statutory responsibility for the inspection of the police forces of England and Wales.
The inspection was conducted to investigate the effectiveness of the force’s response to lessons from the Stephen Port murders.
Between June 2014 and September 2015, Port drugged, sexually assaulted and murdered four young men in East London. Despite the obvious similarities between the deaths, the Met Police Service failed to recognise that they might be connected and considered them non-suspicious.
They even failed to recognise, until after the last death, that Port’s four young victims – Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor – had been murdered, deciding each cause of death was a self-administered drug overdose.
The purpose of the HMICFRS inspection was to establish whether, almost nine years after what it described as a ‘calamitous litany of failures’, the Met had learned lessons and to establish whether such events could happen again.
“History and the findings of this inspection tell us that they will,” the report warns.
“We are especially concerned that deaths considered non-suspicious from the outset could be completely overlooked,” it adds.
Failings in initial investigations into deaths have not been addressed
The report highlights how officers’ initial assessments of Port’s victims were the catalyst for many of the failings that followed, with the HMICFRS concluding that it isn’t confident the Met has addressed these shortcomings.
In the Port case, each of the deaths was treated in isolation, as officers didn’t look for ‘the obvious links between them.’
The report said it was difficult to be reassured that the mistakes made in the Port case couldn’t happen again, as many of the officers who make an initial assessments following a report of death are ‘inexperienced, untrained and poorly supervised.’
“We were disappointed to be told by several officers that identifying links between deaths at a local level relied on luck,” the report says.
“Identifying any links between minor incidents and crimes that may be precursors to more serious events was even less likely. Since February 2022, Basic Command Units analysts have been encouraged to ‘scan’ shown local death reports. We were three examples of this work. We found they were of limited use in their current form.
“We are concerned that there isn’t a pan-London approach to understanding, mapping and potentially linking deaths reported anywhere in the force. We are especially concerned that deaths considered non-suspicious from the outset could be completely overlooked.”
The report highlighted five repeating issues when deaths are investigated by the Met which it says ‘offer the most convincing explanation for why the Port investigations were so badly flawed.’ These are;
- Inadequate intelligence and crime analysis processes – Which can lead to the reliance on luck to identify links between deaths at a local level and make it less likely that any links between minor incidents and crimes, that may be precursors to more serious events, are identified.
- Unacceptable record keeping – Such as poor-quality death reports with basic details omitted or incorrectly recorded, confusing case-management systems, and incorrectly packaged, labelled and recorded property and exhibits.
- Poor oversight and supervision – Such as a lack of supervision when inexperienced response officers attend a report of an unexpected death and inadequate oversight of death reports for the coroner.
- Lack of training – Not enough training provided to instil in officers an investigative mind-set, such as training on coronial matters, sudden death training for response officers and their supervisors, and training to cover the lessons learned from the Stephen Port case.
- Confusing Policy and guidance – Such as an overwhelming amount of policy and guidance (often undated and poorly constructed) that causes confusion.
The report goes on to state that control room personnel ‘generally carried out only basic research to help and potentially protect officers sent to a report of death’.
It says checks are generally concentrated on locations rather than individuals, and don’t, as a matter of course, include Police National Computer or Police National Database checks.
It says such research would have identified Port as a potential sexual predator when he contacted police claiming he had spotted his first victim, Anthony Walgate, when driving past.
A lack of training and, ‘at times laziness’ were also highlighted as an issue, with the report saying there had been occasions when money and drugs were found in a deceased person’s possession at the mortuary, when officers had supposedly searched them at the scene of death.’
Differing methods of reporting deaths to a coroner were also found to have inconsistencies in quality, detail and supervision, with some reports very thorough, but others ‘woeful’ and incorrectly reporting ‘the most basic details.’
Family say failings will ‘cost more lives’
Jack Taylor’s sisters Donna and Jenny Taylor, have previously called for a Public Inquiry into the Met to finally understand ‘how and why the force is failing people so badly’.
Reacting to this latest report, Donna added: “Once again we are reading a report which highlights continuing failings in the Met Police which will put lives at risk.
“The reality is that if police had investigated things properly, Jack could still be here with us today. This report highlights that it was only because of our persistence that police eventually identified Port from a CCTV recording showing him with Jack, and that it was only then that they recognised the links between the four deaths.
“As the report says, that should have been obvious throughout, and had it not been for us, Port would not have been stopped and he would have gone on and killed again.
“Poor investigation and a failure to link similar crimes are the most basic of policing mistakes, and to hear that these kind of basic oversights continue to happen today, is simply appalling, and once again, we just feel so badly let down.
“We’ve heard that procedures are changing and the way sudden deaths are classified has been changed, but what needs to change is attitudes. If officers don’t investigate with the right attitude, and don’t do the basics, these failings will keep happening, and it will cost more lives.”
Solicitor Neil Hudgell, of Hudgell Solicitors, represented the families of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor at the inquest in 2021, at which a jury found police mistakes may have contributed to the deaths.
The coroner reported matters of concern which, without attention, might result in more deaths.
It led to London’s Deputy Mayor for Policing and Crime calling for the HMICFRS inspection, which took place between May and November 2022.
Renewing his own call for a Public Inquiry, Mr Hudgell said: “Here we are, almost nine years on since the appalling approach of Met Police officers meant the deaths of the four young men murdered by Port were wrongly dismissed as non-suspicious, only to be told the some of the same shortcomings still exist today and similar mistakes could be made.
“This report highlights that the most basic requirements of policing are still not being met, from national databases not being routinely checked in cases of sudden deaths to a lack of curiosity in officers, with witness statements being too brief and lacking detail. The basics of policing are not being done.
“Possibly most concerning is the fact that this report has highlighted how inexperienced officers are making crucial decisions when responding to reports of deaths which could impact on everything that then follows in the investigation, with mistakes potentially preventing specialist homicide detectives becoming involved.
“Each and every time a new inspection or investigation is carried out into the Met Police more, quite horrifying shortcomings and failures are identified.
“It has become abundantly clear that this force cannot be trusted to make changes and improvements itself and the Government must step in and oversee proper change across this force.
“If that doesn’t happen, more serious offenders will slip through the net, and more innocent lives will be lost due to the most basic of policing failures.”
The report has made 20 recommendations and has called on Met Commissioner Sir Mark Rowley to treat them as a priority, to ensure such events are prevented in the future.
They include updating out-of-date policies and guidance about unexpected deaths, making sure intelligence checks include national databases, the Police National Database and the Police National Computer and making sure all reports to the coroner for unexpected deaths are signed off by a duty inspector or detective inspector.
The force is also being called upon to ensure it can produce an analytical report concerning its death investigations to gain a better understand of patterns and identify any linked deaths reports.
Read more: The extensive catalogue of police failings which led to the BBC drama ‘Four Lives’
