One of our most important functions at the Independent Police Complaints Commission (IPCC) is the investigation of deaths following contact with the police. The importance of this work means that we need to be confident that we are carrying it out thoroughly, robustly and fairly. That is why we set up this review in 2012, and why we have engaged with a wide range of people, making sure that this included those who have been critical of our approach and our findings.
This has coincided with debates and discussions inside the IPCC about how we work, and how we can ensure quality and consistency. It also overlapped with Dr Casale’s review of our investigation into the death of Sean Rigg, and the findings of the Home Affairs Select Committee’s inquiry into our work. All have recognised that we operate within limited resources and powers; but they also pointed out that we have not always used those resources and powers to best effect.
We know that when we get this work right, the impact is powerful, for the individuals involved, for improved police practice and public confidence. But we also know that where we do not get it right, this adds to families’ distress and to a lack of confidence in us and in the police service.
This review therefore provides us with an opportunity and a challenge. It is one that we are already responding to. We must ensure that we support, manage and train our staff to carry out this challenging and important role. As this progress report shows, we have already made changes to the way we work, and more are planned. We report on them under the three themes that emerged strongly from the review: independence, engagement and effectiveness – qualities that we must be able to demonstrate in our work and approach.
I am very grateful to all those who have given time to this review, or responded to the consultation, and for the assistance of the external reference group. I am especially grateful to bereaved families, for whom this has often meant a painful re-living of the worst time in their lives.
At the end of this year, we will produce a final report, acknowledging in more detail all that has been said to us and setting out our full programme of actions in response. I know that we will be judged, not by the content of any report that we produce, but by the actions we take as a result and the quality and approach of the work we do.
Dame Anne Owers Chair IPCC September 2013
Introduction From the Review
In 2007-08, the IPCC carried out a review (the Stocktake) into the handling of complaints against the police, which resulted in recommendations for change in our own practices and those of the police. In February 2012, we announced that we would carry out a similar exercise in relation to our investigations of deaths during or after police contact – not least because we were aware of some of the criticisms of the way those deaths had been investigated and the outcomes of the investigations.
All deaths and serious injuries during or following police contact must, by law, be referred to the IPCC. They include:
– road traffic fatalities involving the police
– fatal police shootings
– deaths in or following police custody
– apparent suicides following police custody
– other deaths where the actions or inaction of the police may have contributed to the death
We then need to decide whether these cases should be investigated, and if so, how they should be investigated. Sometimes, the death is unrelated to the contact with police: for example where there has been an apparent suicide or a death by natural causes which was clearly unconnected to an earlier interaction between the individual and the police. Other deaths will require investigation, and we must decide whether to carry out a wholly independent investigation ourselves; to manage or supervise an investigation carried out by a police force; or to require the local force to investigate the death itself. Where we consider there may be a connection between police contact and the death, we will investigate independently.
Article 2 of the European Convention on Human Rights (ECHR) places an obligation on the state not to take life, except in very limited and defined circumstances, and to take reasonable steps to protect life where there is a real and immediate risk. If there is an indication that a death may be the result of police action, or failure to act, Article 2 requires there to be an independent and effective investigation to determine the circumstances and causes of the death.1 Our work is an important part of the way the state meets that obligation, alongside the work of coroners and the Crown Prosecution Service (CPS). The obligations arising from Article 2 shape the way that we investigate deaths involving the police. As well as determining how and why a person died, and whether any individuals are at fault, our investigations should seek to ensure that similar deaths can be prevented, and should effectively engage bereaved families in the investigative process.
Therefore, when we conduct an independent investigation into a death, we have a duty to the families of those who have died; we need to retain the confidence of the wider public in the independence and effectiveness of our work; and we must help the police learn the right lessons from these tragic incidents. As such cases inevitably – and quite rightly – attract a great deal of attention, our handling of them shapes public perceptions of the police complaints process and of our own role in holding the police to account. We need to be sure that our investigations are effective and thorough, fully independent of police and other interests, and that we proactively and sensitively engage with the families of those who have died.
Independence of the IPCC
A consistent theme in responses to our consultation is that the IPCC as an organisation, and its investigations, are not believed to be sufficiently independent of the police. Independence is a fundamental requirement of an Article 2 investigation into a death and the IPCC exists precisely for the purpose of providing independent oversight of the police complaints system. Perceptions of a lack of independence therefore have serious implications for public confidence in the organisation, the complaints system and also the police. As has been seen in other areas of public policy, trust in the effectiveness or independence of a regulator is closely aligned to trust in the service itself.
There are two main elements to this criticism:
The IPCC is perceived as too close to the police institutionally and culturally. Many stakeholders were concerned about the number of IPCC staff – particularly IPCC investigators – who are former police officers and police staff. This was seen as resulting in favourable treatment of police officers by the IPCC during investigations. Concerns were raised that the IPCC has a tendency to believe police officers’ accounts without question; that it under-uses its power to interview police officers under caution; and that it allows officers to confer before they give their account of an incident.
The active involvement of police forces in aspects of IPCC investigations is felt to undermine the independence of those investigations. There are two main ways in which this involvement of police in investigations arises:
– Before IPCC investigators arrive at a scene, the local police force is required to take control of the scene and preserve evidence. On arrival, the IPCC may continue to use the local police force to undertake these scene-control and preserving tasks, under its direction, given the small number of staff the IPCC is able to deploy.
– The lack of specialist skills within the IPCC results in the use of experts from local or neighbouring forces to assist independent investigations.
IPCC response to criticisms concerning lack of independence
Ensuring institutional and cultural independence from the police
Independence is a core value for the IPCC and it must be visible in all our work.
We acknowledge the concerns that continue to be raised about our employment of former police officers and staff, and the impact this has on perceptions of our independence. Ex-police personnel bring valuable skills and expertise to the complex and challenging investigative work that we do. However, we need to ensure that their skills and experience are deployed as part of a diverse and multi-disciplinary staff team. For that reason, we have taken active steps to re-balance the investigative workforce to employ more investigations staff from non-police backgrounds, including in senior positions, and we will continue to do so as the organisation expands.
At the same time, we are ensuring that investigators work as part of a wider multi-disciplinary team, including lawyers, press officers and, crucially, commissioners. The IPCC’s commissioners (who can never have worked for the police) provide independent oversight of all IPCC investigations and have overall accountability for this work. It is vital that their role is carried out effectively. For that reason, we have clarified and strengthened the role of commissioners in independent investigations, issuing new guidance earlier this year for our largely new commissioner team. Commissioners are a key part of the safeguards and assurances for families and the public about the independence of our investigations, but independence is not just the preserve of commissioners. It is essential that this is reflected in the culture and approach of all those who work for us, whatever their previous background.
The IPCC accepts that specific concerns are raised when ex-police staff investigate individuals in their former force. There are currently practical difficulties in ensuring this never happens, due to existing staffing and resource constraints in the Investigations directorate. New recruitment and the proposed expansion of the IPCC provide an opportunity to change our allocation procedures to address this concern directly. In the meantime, we have a process in place to actively identify and take action in relation to any direct conflicts of interest in each IPCC investigation.
Avoiding over-reliance on the police in investigations
The IPCC recognises that taking early control of the scene of an incident involving a death or serious injury is an important part of ensuring public confidence in its investigative work. The time immediately following a serious incident, when the scene and evidence is initially secured and key accounts are taken, is vitally important for an effective investigation.
The small size of the IPCC and its responsibility for the whole of England and Wales presents significant challenges for the fast deployment of IPCC investigators to the scene of an incident. The IPCC is reliant on the local police force to notify it of a death and to secure the scene and evidence initially. This will continue to be the case, even if the IPCC increases in size and has more investigators in more locations.
However, we propose to take steps to reduce our reliance on the police where possible and, where we have to rely on police, to be clear about what we require them to do and to hold them to account if they do not meet these requirements. We are doing more to ensure that:
– the police inform us about a death without delay
– IPCC investigators arrive at the scene as quickly as possible
– clear and confident direction and guidance is provided to police at the scene both before and after the IPCC arrive
– we use a wider range of experts in our independent investigations, including non-police experts and those who can provide advice on key issues in a particular investigation, for example relating to mental health or race.
IPCC engagement with bereaved families
Engagement with bereaved families is a fundamental aspect of all IPCC investigations into cases involving a death, and is essential in meeting the IPCC’s Article 2 obligations.
Our approach to engagement with families attracted a great deal of criticism during the review. The listening days organised by INQUEST allowed some bereaved families to express their strong feelings about poor or insensitive practice in our interactions with them. We have also seen some examples of good practice, showing what can and ought to be done: offering condolences; giving clear advice about the IPCC’s role; independence and the process of investigation; tailoring support to the families’ needs and wishes; and maintaining open on-going communication with the family.
However, it is clear that this good practice has not been consistently applied across our investigations and that the families who responded to the review in general felt that they had not been treated sensitively enough or had sufficient involvement in the investigation process. Three themes emerged:
– Inappropriate and insensitive styles of interaction: Families undergoing the pain of recent and traumatic bereavement have reported occasions of being treated without sufficient courtesy, empathy or respect by IPCC staff.
– Lack of information: Bereaved families said that they had not always received the information they wanted and needed during the IPCC’s investigation. For example:
– Many families felt that insufficient information was provided on the process itself including the roles and responsibilities of IPCC staff; how the family can participate in the investigation and what their rights are; and where to go for independent advice and support.
– Updates on the progress of investigations were not frequent enough, or were not provided when promised. Too often they took the form of impersonal template letters, simply listing actions being undertaken rather than providing meaningful information.
– information was not passed on to families and there was inadequate or inconsistent explanation about lack of disclosure.
Inadequate engagement: There were criticisms of the IPCC’s general approach to engaging with bereaved families:
– There is no clear protocol guiding IPCC staff’s work with families.
– Some families felt that those who had died were wrongly characterised or unfairly judged and in some cases that they themselves were under investigation. Inaccurate information in press releases was particularly distressing.
– In some cases families felt they had too little part to play in developing the terms of reference and were not consulted about the direction the investigation took.
– Families felt that they should have the chance to comment on the emerging findings and draft investigation reports but many were not given the opportunity to comment before reports were finalised.
– Some families felt that the IPCC was too defensive in the face of criticism, which inhibited genuine dialogue and exchange between the IPCC and families.
IPCC response to criticisms around engagement with families
Improving our engagement with families
Families should be at the heart of any IPCC investigation into a death. Our investigations should seek to answer the questions they have about what happened to their relative who has died. It is vital to our effectiveness that families feel that they can trust the IPCC to find the truth about the circumstances leading to the death of their family member.
We agree that we need to improve our engagement with families as a matter of priority, to ensure that it is proactive and sensitive and that families are as engaged as they can be, or want to be, in the investigative process. This is not only good practice, it is also a requirement of any investigation into a possible breach of Article 2 of the ECHR. We know, from the families we have heard from, that where we have been able to establish and sustain good and professional relationships with families, this has had a positive effect on trust in the investigation – provided that the investigation itself is thorough – even if the outcome is not what the families expected or hoped for.
All the IPCC’s dealings with families need to be informed by the understanding that they have experienced a bereavement in what are usually highly traumatic circumstances and that they are probably going through the worst experience of their lives. We need to show respect and sensitivity in relation to their loss. Open and sensitive early contact is crucial, even though this is the most difficult time for families; it is also important to maintain and develop the relationship as the investigation progresses.
Effectiveness of IPCC investigations
The quality and thoroughness of IPCC decision-making and investigative work attracted considerable concern. Concerns were also raised about the limited impact of IPCC investigations, both in terms of how individual officers are held to account and the implementation of long-term changes to prevent future deaths.
Stakeholders on all sides identified the strain on the IPCC’s resources as having an impact on effectiveness. Funding limitations were felt to affect decisions made by the IPCC about whether to conduct independent investigations as well as the timeliness of investigations. Capacity issues were said to lead to frequent changes in lead investigator, as well as an over-reliance on police resources in investigations. However, the issues identified go beyond problems of limited resources, with criticisms of the robustness and thoroughness of approach, and about gaps in skills, expertise and guidance.
Below, we identify the key issues raised in relation to the different processes in an investigation. Background information about the investigative process is included in Annex A of this report.
Key issue 1: Decisions about whether the IPCC will investigate an incident – timeliness, consistency and transparency
– The IPCC’s decision-making about whether to investigate an incident involving a death is described by a range of stakeholders as lacking in transparency, inconsistent and shaped by factors other than the seriousness of the case (such as resource constraints).
– Delays in the IPCC making a decision about whether to independently investigate a case are also noted by some stakeholders.
– Many stakeholders consider that the IPCC should independently investigate all deaths that have occurred during or after police contact.