“(4A) On a review applied for under sub-paragraph (1B), the relevant review body must determine whether the outcome of the complaint is a reasonable and proportionate outcome. (4B) In making a determination under sub-paragraph (4A), the relevant review body may review the findings of the investigation.”
“Allegation 1: GMP should have investigated domestic abuse allegations against Teresa’s former partner Robert Chalmers both whilst she was alive, and after her death. You are dissatisfied with both areas of investigation. The investigation report by DS Greetham identifies a number of issues where policy was not followed, which do not require repeating here, but Ms McMahon wishes to emphasise the following. In the IOPC review report, upholding that request, the reviewer, Clare Avrill states, “Teresa is described by the investigating officer as not engaging with officers, or hesitant to provide further details of the situation, and she informed officers that she did not wish to proceed with any further police action against Mr Chalmers. The reinvestigation could consider what Teresa’s motive would be behind this, was she afraid of repercussions, or experiencing coercion and control within her relationship with Mr Chalmers.”
“7. You also raised the following concerns which I am unable to consider: a) DI Humphreys, the Senior Investigating Officer (SIO) in respect of Teresa’s death, did not secure the BWV footage recorded by PC Keen as part of his investigation. b) The statement of DI Humphreys is littered with inaccuracies which are contradicted by BWV footage of the scene and of neighbours being spoken to. c) The review of DI Humphreys’ investigation, conducted by DCI Jenkins, did not consider the BWV footage referred to in (b). The investigation conducted by DI Humphreys is outside of the remit of this review and as such I will not consider these matters. Please note that should you wish to raise any new complaints, which have not already been recorded and considered by GMP, you should contact GMP directly.”
“I have reviewed the investigation carried out by DI Humphreys into the death of Teresa McMahon. As the Senior Investigating Officer (SIO) for a Special Procedure Investigation (SPI), there is an expectation that the officer will take command and control of the investigation including their attendance at any relevant scenes. The primary role of the SIO is to identify if there are any suspicious circumstances or evidence of third-party involvement in the death being investigated. If the SIO is satisfied that there is no evidence of this, their role is then to support the coroner in understanding how the relevant person died. I am aware that you have been granted interested party status for the inquest into Teresa’s death. As a result, you have been provided access to the material generated within the investigation, including the statement of DI Humphreys. His statement outlines the investigation into the death, therefore I do not intend to detail all aspects of the investigation. In terms of the home address where Teresa was found deceased. There was no evidence to support that there had been a struggle, disturbance or that the property had been tidied to conceal that a crime had been committed. There is no evidence to support that anybody entered the address prior to Teresa being found. Other than the evidence that Robert Chalmer entered on his own when he attended with his father and then again when he re-entered with Teresa’s father a short time later. This is when Teresa was discovered deceased. An examination of Teresa’s body did not identify any injuries that could not be accounted for. The scene examination did not identify any evidence of third-party involvement. I am aware that you were concerned that a forensic examination did not take place. There is no expectation for the SIO to request a forensic examination of the scene unless there is evidence that a crime may have been committed, this forms part of the training provided to SIO’s. Having considered the investigation I am satisfied that a Crime Scene Investigator would not have advanced this investigation and it was appropriate for the SIO not to request their attendance. Teresa’s ex-partner Robert Chalmers was present when Teresa was found deceased. There is an omission within his statement that he had entered the address alone prior to entering with Teresa’s father. The SIO has considered the relevance of this omission. There is evidence from Robert Chalmers’s father that Robert entered the address shortly before alone. The short period between these two entries and likely time of death support that this omission had no bearing on her death. DI Humphreys did consider if Robert was involved in the death, but there is no evidence of this. Through the forensic examination of Teresa’s mobile phone and corroboration of data obtained from the network provider. The SIO was able to evidence communication between Teresa and Robert shortly before her death, but that they were in separate locations. The phone work corroborated Roberts account regarding his movement leading up to Teresa being found. I support the SIO’s assessment that Robert Chalmers was not involved in the death of Teresa. In conclusion, I am satisfied that the SIO has undertaken a thorough and professional investigation. All reasonable lines of enquiry have been identified and completed. I have not identified any further actions that should be completed. I support the SIO’s conclusion that there is no evidence of third-party involvement or suspicious circumstances surrounding the death of Teresa.”
“In conclusion, I believe that all available evidence suggests that Teresa tragically took her own life by hanging with a ligature. In contrast, that there is no evidence of criminality or third-party involvement. In my view, a reasonable and proportionate investigation has taken place into the circumstances of her death lead by DI Humphreys. Subsequent reviews, including my own have not led to the discovery of any evidence that supports a hypothesis of homicide.”
“GMP’s initial response to Teresa’s disclosure that she had been subjected to domestic abuse. 13. In my opinion, the available evidence indicates that there were organisational failings in the time it took for GMP to respond to Teresa’s allegation of domestic abuse and how quickly she was seen by police. I will explain my reasoning. 14. In her report, the IO provided an accurate summary of Incident Log 591-120721 which records the steps taken after Teresa made her application for a DVDS disclosure on12 July 2021 . This log shows that it was nine days, from the submission of the DVDS application, until Teresa was visited by PC Keen on21 July 2021 . The IO acknowledged that this delay was too long and conducted a detailed investigation into why this delay occurred, including obtaining a quality assessment of the incident logs related to the case, from the Force Contact Centre (FCC) and obtaining a review of the contact that Teresa had with GMP, from DCI Lindsay Booth of the Public Protection Governance Unit (PPGU). 15. In my opinion, the available evidence supports the IO’s conclusion that the initial assessment of the DVDS application, undertaken by Civ. 71020 Mottram, and the action taken by them, to book an appointment for Teresa to attend the police station the following day, was appropriate. I am of this opinion because I have reviewed Incident Log 591-120721, GMP’s Incident Response Policy and the FCC Quality Assessment of the incident logs. Civ. Mottram assessed the initial DVDS application as a Grade 2 priority. This was in keeping with the force policy at the time, as confirmed within the FCC quality assessment document. 16. PS 17117 Potts then reviewed the incident log and changed the risk level to low, suitable for a domestic abuse appointment. The IO acknowledged that this decision was premature. This conclusion is supported by the FCC quality assessment document, which indicated that further background checks should have been conducted. The IO identified individual learning for PS Potts in respect of this matter. In my view, this is an appropriate action to take to improve performance, however as PS Potts is now retired this learning will not be delivered. 17. PC 08292 Sharrocks telephoned Teresa on12 July 2021 and booked her an appointment to attend Swinton Police Station the following day. I am of the view that the available evidence supports the IO’s conclusion that this course of action was appropriate. I am of this opinion because I have listened to the telephone conversation, between Teresa and PC Sharrocks, and in my view, the information provided by Teresa meets the criteria for a low priority incident, as defined within GMP’s Incident Response Policy. 18. Unfortunately, after booking Teresa’s appointment, PC Sharrocks failed to take the required administrative action, which meant that when the appointment was subsequently cancelled, this was not picked up and no attempts were made to rearrange the appointment. The FCC quality assessment of the incident logs indicated that the case sat in the wrong queue, without anyone having ownership of the case, until it was picked up again on19 July 2021 . The case was then allocated to PC Keen on21 July 2021 . The IO identified individual learning for PC Sharrocks in respect of this matter. In my view, this is an appropriate action to take to improve performance, however the IO confirmed that this learning would not be delivered because PC Sharrocks was on leave, pending retirement. 19. In my view, it is unclear whether Teresa was aware that her appointment at Swinton Police Station had been cancelled. The IO indicated that there is some evidence which suggests that Teresa did not attend the appointment, firstly because no information was added to the incident log to indicate that she had attended, and secondly, because one of Teresa’s friends had made the comment ‘Teresa called up about a Clare’s Law disclosure but didn’t go’. However, in my view, there is insufficient information to conclude, with certainty, whether Teresa had made the decision not to attend the appointment, or whether she had been informed that the appointment had been cancelled. 20. In your application for review, you indicated that the IO had failed to consider the effect that the delay in police visiting Teresa had on how she felt about pursuing her allegation of domestic abuse against Mr Chalmers. In my view, the IO has acknowledged this impact. I am of this view because, in her report, the IO stated, ‘it is accepted that the delay in seeing Teresa, whilst not necessarily being the cause of her change of heart, would have done nothing to inspire her with confidence that her concerns were being taken seriously’. 21. Overall, I am of the view that the available evidence supports the IO’s conclusion that the issues which delayed Teresa being seen by police were caused by human error. In my view, the individual learning identified by the IO was appropriate to address these matters. It is my opinion that, whilst unfortunate, the delay did not prevent GMP from investigating Teresa’s allegation of domestic abuse. I am of this view because the case was allocated to PC Keen, on21 July 2021 , who progressed the investigation. Investigation conducted by PC Keen. 22. Having compared the actions taken by PC Keen, with the guidance outlined in GMP’s Domestic Abuse Policy, the IO concluded that she could not identify any failures except for PC Keen not marking her BWV footage as evidential. In my opinion, this conclusion is supported by the available evidence. I will explain my reasoning. 23. The available evidence confirms that PC Keen visited Teresa’s home on21 July 2021 . At 12:29pm, on21 July 2021 , PC Keen created a Domestic Abuse Record (known as the ‘DAB’), in accordance with GMP’s Domestic Abuse Policy. The DAB includes a detailed overview of the information provided, by Teresa, to PC Keen. The IO has provided a summary of this information in her report, and I will not repeat it here. The DAB indicates that Teresa did not wish to provide much detail, with regards to the assault that she had alleged. She did not want the crime to be progressed and did not support a prosecution of Mr Chalmers. Teresa confirmed that the relationship with Mr Chalmers had ended, and that she had no intention of getting back into a relationship with him. 24. At the same meeting, PC Keen completed the DASH Risk Assessment with Teresa. DASH stands for ‘Domestic Abuse, Stalking / Harassment, Honour-Based Abuse’ and is a national risk identification tool which can be used by professionals to identify and assess the risk to victims of domestic abuse. Teresa declined to answer the DASH questions, however, as per the requirements of the GMP Domestic Abuse Policy, PC Keen included available information on the DASH form and made a professional judgement as to the level of risk, which she viewed to be medium. According to the GMP Domestic Abuse Policy, a medium risk is given where there are indicating factors of serious harm, but this is not thought to be imminent unless there is a change in circumstances. 25. In my view, the available evidence indicates that PC Keen made attempts to explore, with Teresa, the reasons for her reluctance to provide further details of her relationship with Mr Chalmers and her rationale for not wanting to pursue police action against him. I am of this view because Teresa’s responses are recorded in the DAB and in the DASH risk assessment, in which PC Keen noted ‘Victim would not answer the DASH questions stating that she does not want anything to come back from her report. She initially wanted a Claire Law (sic) and was not disclosing any offences. She would not go into detail about what had happened during their relationship’. 26. Following her visit to Teresa, PC Keen submitted a crime report, CRI/06FF/17809/21 for a section 39 common assault, with Teresa as the victim and Mr Chalmers as the suspect, a summary of which is included in the IO’s report. PC Keen recommended that the crime was sent for closure, because ‘the victim does not support and does not wish to pursue this further’. PC Keen also noted that there were no further potential lines of enquiry to follow. On26 July 2021 , Inspector 14451 Struttman confirmed that the crime could be closed, with no further action, pending any further information coming to light. During the investigation of your complaint, the crime report (CRI/06FF/17809/21) and DAB, submitted by PC Keen, were reviewed by DCI Booth, who did not identify any concerns regarding the action taken. Action taken by PC Doherty. 27. The GMP Domestic Abuse Policy indicates that the District Safeguarding Team triage all medium risk domestic abuse events. In Teresa’s case, PC 11343 Doherty undertook this triage. 28. On22 July 2021 , PC Doherty conducted the triage on the DAB completed by PC Keen. The actions taken by PC Doherty were reviewed by DCI Booth, who concluded that she had conducted a thorough risk assessment. 29. Having reviewed the information recorded by PC Doherty on the DAB, I am of the view that her actions were in line with the requirements of the GMP Domestic Abuse Policy. I am of this view because the policy specifies actions that should be taken by the person conducting the triage and, in my view, where applicable, these actions were carried out by PC Doherty. As per the policy, the notes recorded by PC Doherty on the DAB log, indicate that she attempted to contact Teresa within 72 hours of conducting the triage. This is supported by the telephone audit, obtained by the IO, which confirmed that PC Doherty attempted to telephone Teresa on the 22 and29 July 2021 and the5 August 2021 . Unfortunately, these calls went unanswered. 30. The GMP Domestic Abuse Policy requires the person conducting the triage to conduct a number of checks, on police systems. In my view, the notes recorded by PC Doherty, on the DAB, indicate that these checks were made. 31. The policy also requires the person conducting the triage to identify suitable support agencies to signpost victims to. The IO asked PC Doherty to confirm what she would have done had she been successful in her attempts to contact Teresa. In her account dated22 February 2023 , PC Doherty confirmed that she would have discussed safeguarding, offered Teresa support services (which she named), and asked if Teresa had any mental health issues. PC Doherty also confirmed that she would have further discussed the DVDS application, this matter will be addressed in my assessment of allegation three.”
“50. In conducting my assessment of allegation two, I have firstly considered whether Teresa provided any information, either via the DVDS disclosure application, or in person when she spoke to PC Sharrocks, to indicate that she should be identified as ‘vulnerable’. In doing so, I have referred to the definition of ‘vulnerable’ taken from the THRIVE risk assessment guidance, which explains that ‘a person is vulnerable if, as a result of their situation or circumstances, they are unable to take care of or protect themselves, or others, from harm or exploitation’. 51. In respect of the information provided in the DVDS application, there is insufficient evidence to suggest that Teresa met the criteria for being identified as vulnerable. 52. In respect of the conversation between PC Sharrocks and Teresa, I have reviewed Incident Log 591-120721, which shows that at 09:33am on12 July 2021 , having spoken to Teresa, PC Sharrocks completed a THRIVE assessment. The IO provided information on the THRIVE assessment process in the form of a GMP training presentation. The person making the assessment is required to identify a risk level, provide their rationale for this, and identify whether the person in question is vulnerable. Incident Log 591-120721 shows that PC Sharrocks identified a low risk level for Teresa. His rationale for this decision was that Mr Chalmers was now Teresa’s ex-partner and they did not live together. PC Sharrocks also noted that Teresa had ‘no known vulnerability’. Having listened to the call between PC Sharrocks and Teresa, I can’t identify any information that would suggest that Teresa met the criteria for being identified as vulnerable, as described in paragraph 50 of this letter. For these reasons, I am of the view that it was reasonable for PC Sharrocks to indicate that Teresa had no known vulnerability. 53. In respect of PC Keen, the information recorded in the DAB record, Crime report CRI/06FF/17809/21 and DASH risk assessment does not include reference to Teresa having disclosed any vulnerability factors. PC Keen has specifically recorded that no issues relating to alcohol or mental health were disclosed by Teresa when she visited her. As such, I am of the view that PC Keen was not in possession of information which indicated that Teresa was vulnerable. 54. In addition, the IO concluded that despite PC Keen having no reason to doubt that Teresa’s relationship with Mr Chalmers was over, she addressed the risk that they may rekindle their relationship by offering safeguarding advice and discussing longer term safeguarding measures. In my view this conclusion is supported by the DAB completed by PC Keen, which indicates that she provided advice to Teresa, in respect of what action to take if Mr Chalmers came to her home, discussed options for longer term safeguarding actions and provided details of agencies that Teresa could contact for support. 55. I have also considered whether GMP was in possession of any information about Teresa, prior to her DVDS application on12 July 2021 , which could have led them to identify Teresa as vulnerable, as per the definition outlined in paragraph 50 of this letter. 56. The IO determined that GMP were unaware of Teresa’s mental health, previous attempt to take her own life, medication and alcohol consumption. In my view, this determination is supported by the available evidence. I am of this view because the IO has confirmed that prior to the incidents to which this complaint relates, there was no information held on GMP systems, relating to Teresa, except for two unrelated historical matters. 57. In the additional information you submitted in support of your application for review, you indicated that the IO’s conclusions, about whether GMP should have identified Teresa as vulnerable, were based on what officers and staff knew at particular times, in respect of certain information. In your view, the IO should have considered the totality of the information in the overall context. Taking into account the available evidence, including what was known to individual officers, and the information available to GMP as a whole, I am of the view that the IO has provided a reasonable rationale as to why Teresa was not identified, by GMP, as vulnerable. 58. The IO has determined that the service provided by GMP was acceptable. From the evidence and explanations I have reviewed, I am in agreement. I conclude that the outcome of this complaint was reasonable and proportionate.”
“In the iopc report dated 22nd of September 2023: Ms Watters acknowledged that she had listened to the telephone conversation on the12th July 2021 , between PC Sharrocks and Teresa McMahon . Ms Watters believed that the information provided by Teresa meets the criteria for a low priority incident. I have listened to the recorded telephone conversation which was disclosed to me by the coroner on the30th November 2023 . Within Ms Watters review , she has failed to acknowledge a serious allegation made by Teresa in this call : broken rib and fingers . This allegation should have been logged as ABH, not common assault. Ms Watters has also failed to acknowledge the obvious fear which can be heard in Teresa’s voice , specifically at the prospect of officers attending her home. It is clear in this recorded telephone conversation that Teresa was concerned about repercussions should her ex partner become aware that the police had attended her home. It is also clear that Teresa appears vulnerable and frightened. PC Sharrocks picked up on Teresa’s concerns, and gave her an option to attend a police station. After listening to this call it is clear that the police should have sent a response unit to Teresa’s home the same day . I am of this belief because the officer was aware of the suspect's previous charges and convictions . The officer was also aware that Teresa was frightened and fearful of her ex partner . Teresa told the officer that Rob had also attacked and strangled another ex partner , and was constantly attempting to get back into Teresa’s life. Within this call Pc Sharracks does not appear to have any genuine concerns for Teresa’s safety. I therefore believe that the following decision made by Rachel Watters: “ in my view, the information provided by Teresa meets the criteria for a low priority incident, as defined within Gmp‘s incident response policy” , to be unlawful . The evidence which I will rely upon is the recorded telephone conversation between Teresa and PC Sharracks on the12th July 2021 . In her report Ms Watters repeated and relied upon information given to her by the IO . This is in relation to a section 39 common assault. However the allegation which Teresa made on the12th July 2021 to PC Sharracks in the recorded call , which Ms Watters has listened to, was that her ex partner had broken her rib and fingers . Therefore this allegation should have been logged as ABH not common assault . If this had been the case then the 6 months time limit would not have applied.” ii) Paragraphs 58-59: “Rachel Watters believes that there was no evidence in the telephone call which suggests that Teresa was vulnerable. She also believes that the officers could not have known if Teresa was vulnerable as Teresa did not disclose she was vulnerable. I agree with the first iopc case manager , it appears that the police are victim blaming Teresa for not disclosing her vulnerability. The definition of vulnerable is not isolated to the references made in Ms Watters review. A person can suddenly become vulnerable at any time depending on their circumstances . The definition of vulnerable can also mean a person who is exposed to the possibility of being attacked or harmed, either physically or emotionally. I therefore believe that it is paramount that the deciding Judge in this case listens to the three minute recorded telephone conversation, between Tereasa and PC Sharrocks on the 12th of July 2021, before coming to a decision whether Teresa was or was not, vulnerable at that time.”
“25. Medical evidence obtained for coronial investigation DS Manning reviewed the medical evidence as part of her overall review into allegations of controlling and coercive behaviour (further discussed below). I have had sight of the pathology report of Teresa’s autopsy from the Coroner’s office. There is nothing to suggest Teresa was the victim of any serious domestic violence in the report. With regards to broken bones, no gross deformity was noted. DS Manning also reviewed a letter from Teresa’s GP which was found to sum up Teresa’s medical history. Teresa tested positive for Covid on26/07/2021 . She had a long history of mental health problems and had received support. She took an overdose in 2004. Alcohol problems are referred to in 2007 and 2010. She was recorded as drinking 20 units a week in 2020. She was assessed by psychology in 2010 but did not engage. Panic attacks are mentioned several times, the last time being November 2020. She was taking Sertraline and Amitriptyline. There was no mention of any broken bones or domestic abuse in the GP report.”
“PC Keen has recorded a crime appropriately and set a medium risk DASH which appears appropriate to the circumstances provided by Theresa. Medium is described as there are indicating factors of serious harm, but this is not thought to be imminent unless there is a change in circumstances. It is difficult to fully assess the risk when the DASH questions were refused. Theresa had documented suicidal thought in her diary on the 23rd June yet made no disclosure of this to PC Keen on the 21st July. This is not intended as a criticism of Teresa. The medical evidence gathered within the coronial investigation relating to Teresa’s mental health, previous suicide attempt, medication and her alcohol consumption was not information known to GMP when Teresa was alive. Officers would have been totally reliant on what she told them. Looking at PC Keen’s updates Teresa did not disclose this information which is highly likely to affect a risk assessment.”
“She was asked about the comments she made in relation to Robert breaking her ribs and fingers again she would not go into too much detail only saying that he has grabbed hold of her hand squeezing her fingers and has grabbed her around the waist squeezing her ribs causing them to break. Teresa states that her ribs were broken in October 2020 and her fingers were broken around 6 weeks ago. However, Teresa has not sought any medical attention to either assault, so it is unclear if her fingers and ribs were actually broken. Teresa states that her ribs hurt for some time after and she was left with some reddening on her stomach and has full use of her fingers. Teresa stated that she does not want to support a prosecution or provide many details because she does not want this to be brought up and feels like it might cause further issues. She confirmed that hers and Robert’s relationship has ended, and she has no intention in getting back in a relationship with him.”
“Deletion of PC Keen’s BWV footage. 32. It was confirmed, in the original complaint investigation (conducted by DC Richard Sample), that the Body Worn Video (BWV) footage recorded by PC Keen, when she attended Teresa’s home on21 July 2021 , was no longer available. The explanation of why the BWV was not available was limited, stating simply that this was due to a ‘system fault’. In your complaint, you raised concerns about why the BWV footage could not be obtained. In order to address these concerns, the IO conducted a thorough investigation into why the BWV is no longer available. The IO found no evidence that PC Keen had wilfully sought to hide the BWV footage she had recorded and concluded that the deletion of the BWV footage resulted from an administrative error. 33. In my opinion, this conclusion is supported by the available evidence. I am of this opinion for the following reasons. Firstly, PC Keen acknowledged, in her statement dated10 May 2023 , that she incorrectly flagged the BWV footage, which meant that it had not been saved. 34. Secondly, PC Mark Jones, from the Digital Futures Team, completed an audit of the BWV footage related to the case, and confirmed that whilst the relevant footage had been flagged with a ‘Domestic Abuse’ marker, on20 August 2021 , an evidential retention maker was not applied. This meant that the BWV footage automatically deleted after 28 days. PC Jones confirmed that the footage had self-deleted, it was not manually deleted, and it was not possible, for any officer, to delete BWV footage from the system. 35. Thirdly, PC Jones confirmed that it was PC Keen who added the ‘Domestic Abuse’ maker to the footage on20 August 2021 . The IO concluded that this would indicate that PC Keen’s intention, after learning of Teresa’s death, was to ensure that the footage was retained. In my view this is a logical conclusion. 36. In the additional information you provided in support of your application for review, it was stated that you had been given inconsistent information about the availability of PC Keen’s BWV footage. In my view, the IO has conducted thorough enquiries to investigate why the BWV footage was not available, and to provide reassurance that it is not possible for an officer to delete footage from the BWV system. 37. In my opinion, appropriate actions have been taken to address the error made by PC Keen. PC Keen’s account indicates that she acknowledged her error and was now aware of the correct process for marking BWV footage so that it is saved. In addition, the IO confirmed that changes have been made to the BWV system to ensure that footage marked as ‘Domestic Abuse’, and with no other markers added, would now be retained for six years. This was confirmed by PC Mark Jones, from the Digital Futures Team in an email dated23 May 2023 . The IO also acknowledged that the original complaint investigation, conducted by DC Sample, could have probed further into why the BWV was no longer available and offered an apology for any confusion and distress this had caused to you.”
“Information provided to Teresa by PC Keen. 62. In my opinion, the available evidence indicates that Teresa was provided with inaccurate information about her eligibility for a DVDS disclosure by PC Keen. I am of this opinion because it is clear, from the DAB and DASH Risk Assessment form, that PC Keen advised Teresa that she would not be entitled to a DVDS disclosure because she was no longer in a relationship with Mr Chalmers. In her statement dated10 May 2023 , PC Keen acknowledged this error and indicated that she had since discovered that a DVDS disclosure can be provided to individuals who are in a relationship and those who are not in a relationship. 63. However, in my view, PC Keen’s error did not impact on whether the DVDS disclosure was made to Teresa. I am of this view for two reasons, firstly, because it was not PC Keen’s role to make a decision on the DVDS disclosure and secondly, because the decision on whether the disclosure would be made was outstanding at the time of Teresa’s death. Actions taken by PC Doherty. 64. In her account dated22 February 2023 , PC Doherty confirmed that she would have been responsible for deciding whether Teresa would be provided with a DVDS disclosure. In her report, the IO referred to the DAB completed by PC Keen, which was then added to by PC Doherty. The DAB records the actions taken by PC Doherty, in respect of Teresa’s request for a DVDS disclosure. The IO has provided a summary of the document in her report, and I will not repeat it here. 65. As part of her investigation, the IO asked DCI Booth to review the DAB and provide her comments on the actions taken. DCI Booth acknowledged that the process followed by PC Doherty would not be advocated within the new DVDS Policy. The IO indicated that this is because, in the circumstances in this case, the decision about whether or not to make a DVDS disclosure should be made by a sergeant. However, DCI Booth confirmed that the process followed by PC Doherty was being replicated across several districts at the time, and that the policy in place was unclear as to the action that should be taken. I also note that PC Doherty confirmed, in an email to the IO on23 February 2023 , that had she been unsure about whether or not the DVDS disclosure should be given, when she had come to make that decision, she would have spoken to her sergeant or inspector. 66. In her report, the IO noted that PC Doherty recorded the following, on the DAB, in respect of a DVDS disclosure; ‘N/A- no longer in a relationship. Teresa has been informed that she does not meet the criteria for disclosure.’ The IO asked PC Doherty why she had included this information on the DAB. PC Doherty confirmed, in her account dated22 February 2023 , that she had done so in reference to the fact that PC Keen had informed Teresa that she was not eligible for the disclosure. The IO indicated that PC Doherty should have amended this information, if she believed it to be incorrect, and in my view, this is a reasonable conclusion. As such, the IO identified individual learning, in respect of this matter, for both PC Keen and PC Doherty. 67. In her report, the IO confirmed that, at the time of Teresa’s death, it had not been decided whether a DVDS disclosure would be made, or what any disclosure would have included. The DVDS policy allows for up to 35 days to make a final decision and at the time of Teresa’s death, the log remained open, and PC Doherty was making active attempts to contact Teresa. In my view, this conclusion is supported by the available evidence. I am of this view because I have read the DVDS policy and reviewed the DAB which was being updated by PC Doherty. PC Doherty recorded, on the DAB, that she had attempted to contact Teresa on22 July 2021 ,29 July 2021 and5 August 2021 and unfortunately did not get an answer. This is supported by the telephone audit data obtained by the IO. Each of these calls lasted a very short time indicating that PC Doherty did not speak to Teresa. Issues with the DVDS policy in place in July 2021. 68. In her statement, DCI Booth provided a detailed overview of the process followed in this case, in respect of the DVDS disclosure. The IO has included the relevant points in her report, and I will not repeat DCI Booth’s assessment here, suffice to say that a number of issues were identified, in respect of the DVDS policy in place at the time of Teresa’s death. The IO confirmed that this policy was updated, in October 2022, to include learning from Domestic Homicide Reviews, HM Coroner reviews and IOPC recommendations. Consideration of whether a DVDS disclosure would have been made to Teresa. 69. Despite the decision not having been finalised, in respect of the DVDS disclosure, at the time of Teresa’s death, the IO conducted enquiries in an attempt to determine whether it is likely that, on the basis of the available information, Teresa would have been provided with a DVDS disclosure. The IO obtained opinions on this matter from Sgt Walsh, DI Poole and DCI Booth. 70. The IO concluded that Sgt Walsh and DI Poole were of the opinion that a DVDS disclosure was not likely to have been made to Teresa. In my view, this conclusion is supported by the email that Sgt Walsh sent to the Serious Case Review on21 June 2022 , in which he stated, ‘the circumstances would not have warranted a DVDS being issued due to TM stating that she was not longer in a relationship with RC and had no plans to resume the relationship.’ It is also supported by comments made by DI Poole, in the PIP2 document, which have been redacted in the IO’s report for confidentiality reasons. 71. In her statement, DCI Booth provided a thorough assessment of whether Teresa could or should have been provided with a DVDS disclosure. In her report, the IO has included a summary of the information provided by DCI Booth, and I will not repeat it here. However, DCI Booth concluded that, had she personally been asked to make the DVDS disclosure, she would have insisted on further contact with Teresa. As discussed in paragraph 67 of this letter, PC Doherty was still attempting to contact Teresa, at the time of her death. In her account, PC Doherty stated that, had she been able to contact Teresa, and there had been any suggestion that she may get back into a relationship with Mr Chalmers, she would have further discussed the DVDS disclosure. 72. During her investigation, the IO identified individual learning for PC Keen and PC Doherty in respect of their understanding of the DVDS scheme. However, she explained that she was satisfied that this individual learning would be addressed by wider measures being implemented by GMP. I contacted the IO to seek confirmation of what action had been taken and she confirmed that the DVDS policy had been updated and launched and that training, to enhance the knowledge and skills of practitioners when making decisions about the DVDS, has been delivered to the safeguarding teams (of which PC Doherty is a member). 73. In addition, the IO identified, during her investigation, that the misconception, that separation is a barrier to disclosure for the DVDS scheme, may be more widely held within GMP. In order to get the message out to frontline officers, the IO submitted organisational learning, via GMP’s internal organisational learning team. As a result of this process, this learning was raised and submitted ‘on Chief Constables Orders’ which reaches every police officer and staff member in GMP. 74. The IO also confirmed that the individual learning for both PC Keen and PC Doherty will be re-enforced, following the outcome of this review, when they will both receive a full copy of the IO’s report along with the new DVDS policy. 75. In the additional information you provided, in support of your application for review, you indicated that you did not understand the IO’s determination that the service provided in respect of complaint three was acceptable, given that the IO had concluded that the DVDS disclosure policy was neither understood nor followed and that learning had been identified for at least two officers. 76. I contacted the IO to seek clarification on this matter and she explained that whilst she had identified learning, she did not uncover anything, during her investigation, which showed that a DVDS disclosure should have been made. The IO confirmed that the final decision on whether to provide the disclosure had not been made at the time of Teresa’s death and she therefore concluded that the service was acceptable. 77. In my opinion, there is insufficient evidence to conclude that GMP should have made a DVDS disclosure to Teresa and failed to do so. I am of this view firstly because a final decision had not been made, in respect of the disclosure, at the time of Teresa’s death and PC Doherty was making active attempts to contact Teresa and discuss her application. Secondly, in my view, the available evidence indicates that GMP had insufficient information, at the time of Teresa’s death, to determine that the criteria for making the DVDS disclosure had been met. 78. In my opinion, the IO has conducted a thorough investigation into this complaint. She has identified both individual learning and organisational learning in respect of this matter and taken steps to ensure that this learning is delivered in the most effective way. In my view, these are appropriate actions to take to improve performance. I conclude that the outcome of this complaint was reasonable and proportionate. 79. In the additional information you provided, in support of your application for review, you raised a concern about the IO’s reference to the ‘myth’ of officers believing that a DVDS disclosure cannot be made when a person has left a relationship. You indicated that you found this term insulting and worrying. Whilst conducting my assessment, I reviewed a set of presentation slides provided by the IO. The slides were for a presentation given by the Serious Case Review Unit, of the Investigation and Safeguarding Review Team at GMP. One of the aims of this presentation was to outline recommendations from Domestic Homicide Reviews which related to DVDS disclosures. In the presentation slides, reference is made to a number of ‘myths’, i.e., misconceptions which officers may hold, in respect of the guidance around DVDS disclosures. In my view, it is likely that the IO used the word ‘myth’ in her report, for this reason, and in order to explain that the need to address this misconception had been identified and addressed by GMP. I hope that this explanation will provide you with some reassurance in respect of why this word was used.”
“38. In respect of the investigation into domestic abuse allegations, made by you after Teresa’s death, the IO determined, having assessed the completed enquiries documented by DS Manning and DI Poole, that the conclusions reached were reasonable. This included the decision not to interview Mr Chalmers. 39. In my opinion, the available evidence supports the IO’s determination. I will explain my reasoning. 40. The IO indicated, in her report, that after Teresa’s death you made a report of controlling or coercive behaviour (CCB) against Mr Chalmers with Teresa as the victim. You also requested that GMP investigate evidence of the assaults that had been disclosed by Teresa, as well as those that had been referred to in text messages after Teresa’s death. DS 13033 Manning and DI 17803 Poole conducted this investigation. 41. In my opinion, it is clear from the PIP2 Action and Review document, and Crime Report CRI/06FF/0030288/21, that a wide range of investigative actions were completed by DS Manning. In her report, the IO listed a number of these actions, and I will not repeat them here. However, I would note that a large amount of information has been included in the PIP2 document, indicating that DS Manning took numerous accounts and statements, reviewed Teresa’s notebooks and communications between herself and her family and friends and reviewed medical evidence. 42. In respect of the allegations of assault, DS Manning concluded that the only evidence she had found of domestic abuse was a S39 assault, for which the six-month statute limit of prosecution had expired. In my view, DS Manning provided a detailed rationale explaining how she reached this determination. DS Manning indicated that whilst she had considered interviewing Mr Chalmers about both this matter, and Teresa’s report that he had hurt her ribs in October of 2020, there was no necessity to do so because Mr Chalmers could not be prosecuted. As SIO of the investigation, DI Poole updated the PIP2 document on27 June 2022 . Having reviewed the actions taken and conclusions reached by DS Manning, DI Poole concluded that ‘there are no grounds to speak to Mr Chalmers as a suspect for assault which was unsupported when Teresa was alive and has passed the statute of limitations for any prosecution’. 43. In respect of the allegation of CCB, DS Manning concluded that she had found no evidence of coercive or controlling behaviour towards Teresa by Mr Chalmers. In my opinion, a detailed rationale was provided, by DS Manning, as to how she reached this determination. DS Manning’s conclusion was supported by DI Poole, who indicated, in her update to the PIP2 document on27 June 2022 ‘based on all of the information that I have read, seen and experienced first-hand there is not enough evidence to corroborate coercive controlling behaviour by Rob Chalmers to Teresa McMahon’. DI Poole concluded that there was no necessity to speak to Mr Chalmers about the allegation of CCB as this had not been substantiated, despite best efforts, and confirmed her agreement that the crime should be closed. 44. Having reviewed the investigation log, DCI Booth concluded that DS Manning and DI Poole had conducted a thorough investigation and stated that she concurred, based on DS Manning and DI Poole’s assessment, that there was insufficient evidence of CCB. 45. The IO concluded that the service, provided by GMP, in respect of allegation one, was acceptable. In your application for review, you questioned why the IO had come to this determination when she had identified a number of organisational failings, and instances of policy not being followed, in respect of allegation one. 46. I contacted the IO to seek clarification on this matter and she explained that whilst she had identified unacceptable delays in the police attending Teresa’s home, she did not believe that these delays impacted on the outcome, and they did not form the basis of your complaint. The IO indicated that your complaint was that GMP did not investigate the allegation of domestic abuse, made by Teresa before her death, or the allegations of domestic abuse, including CCB, made by you after Teresa’s death. Having conducted her investigation, the IO concluded that GMP did sufficiently investigate both matters which led her to determine that the service provided was acceptable. 47. In my opinion, the available evidence supports the IO’s determination that GMP conducted investigations into both Teresa’s initial allegation of domestic abuse, and the allegations made by you after Teresa’s death. Further, I am of the view that the IO has gone to considerable lengths to highlight the failings that she has identified in this case and to thoroughly investigate them. The IO identified individual learning where appropriate and sought reassurances that the necessary changes have been made to processes and systems, to prevent similar issues occurring in the future. As such, I conclude that the outcome of this complaint was reasonable and proportionate.”
“82. Having completed her investigation, the IO indicated that she did not find that there were any indicators or signs of Teresa’s state of mind that GMP missed or failed to address, consequently, she did not identify any opportunities missed by GMP in preventing Teresa’s death. In my opinion, this conclusion is supported by the available evidence. 83. I am of this view because, as outlined in my assessment of allegation two, it is my opinion that GMP were not in possession of information, whether directly reported to them by Teresa, or in respect of records held about her on GMP systems, to know that, at the time of their interaction with her, Teresa may have been experiencing suicidal thoughts. In my view, the available evidence suggests that the officers who interacted with Teresa considered her circumstances and made appropriate determinations as to the risks that she faced in respect of her allegations of domestic abuse. In my opinion, the records made by PC Keen, after visiting Teresa, suggest that appropriate safeguarding information was provided and the details of support organisations that Teresa could contact were offered. PC Keen has specifically recorded, on the DAB log, that Teresa did not have mental health issues. PC Doherty’s account, and the records made on the DAB, indicate to me that, had she spoken with Teresa, she would have asked about Teresa’s mental health. Sadly, PC Doherty’s attempts to contact Teresa were not successful. 84. I am of the view that the available evidence supports the IO’s conclusion that the service provided by GMP was acceptable and the outcome to this complaint was reasonable and proportionate.”
“Our service standards … We also have a responsibility to provide a safe working environment for our colleagues, so we deliver a fair service for all. On the rare occasion that we believe the way a person is communicating prevents us from doing this, we may decide to restrict the nature or frequency of their contact. Meeting the needs of service users and colleagues We will always consider how to adjust our service to meet the needs of the people who use our service. However, our colleagues deserve to work without receiving abuse or other unacceptable contact, and we will support our colleagues to manage these difficult situations effectively. We will make reasonable adjustments (relating to a protected characteristic [Footnote 1 –Equality Act 2010 ]), for example provide communications in large text format for someone who is visually impaired, or support people to make complaints over the phone in the way we deliver our services. We may still consider it appropriate to restrict contact with people who have a reasonable adjustment in place. This will be a last resort and will depend on all the circumstances of the case. … Defining unacceptable contact Contact (by any form of communication) is unacceptable if it is: • aggressive or abusive, or • unreasonably persistent, or • an unreasonable demand andcould cause our colleagues to feel harassed, distressed, threatened or afraid, or reduce our ability to provide our services to any service user, or meet our statutory obligations. … > Unreasonably persistent contact We recognise that some people might be unwilling to accept a decision or action we have taken, or that there are some things we simply cannot do. However, we may consider contact to be unreasonably persistent where we have already fully advised the service user of the decision, explained the decision to them if needed and they continue to contact us to challenge the decision. If this leads to someone making unwarranted allegations against our colleagues, it will not be tolerated. > Unreasonable demands Each case will be assessed independently. However, it is likely that the following types of demand will be considered unreasonable: • timescale demands (other than those we work towards) • demands for a specific colleague or team to carry out a task • demands made to more than one IOPC team or colleague (i.e., sending the same request to difference colleagues) • making repeated or multiple demands which are substantially the same • demands for things we cannot do, whether for practical or legal reasons. • unreasonable escalation of complaints Unreasonable amounts of contact may also amount to an unreasonable demand. This includes inundating colleagues with information or repetitive communications, content which is difficult to read or understand (subject to specific needs or adjustments), or material which is not directly relevant to our work. Managing unacceptable contact We will do all we can to resolve an issue while abiding by our Service Standards, before the putting a restriction in place. We will not remove a person’s access to our colleagues without good reason and it will only be a last resort. To manage a person’s contact, we may decide to restrict the nature or frequency of contact in the following ways: • terminate phone calls (if the caller is being abusive to a colleague for example) • restrict times, days or durations of permitted contact (for example, if there is excessive and repetitive contact) • allocate reasonable times to respond (if there is excessive and repetitive contact for example, which impacts our ability to respond to other service users) • assign a single point of contact to the person (for example, if a person attempts to contact various members of colleague with the same issue) • limit the ways in which a person may contact us (for example, if a person is abusive or harassing colleague, or making excessive contact via email/phone) • read but not respond to communications (for example, if there is excessive and repetitive contact and the matter has already been addressed) • report unacceptable contact to the police (for example, if contact is abusive/threatening) We will always try to work with people to understand their needs and how they can be met. We will be transparent and inform the person before deciding to put a restriction in place due to unacceptable contact. “We will always attempt to warn a service user that we consider their contact unacceptable before making a restriction decision. …”
“….. I have previously explained that Lucas will remain your nominated individual in the Customer Contact Centre (CCC) at this time; I will not discuss this point further. ….. My previous correspondence in relation to you submitting further reasons for your review in writing apply. Finally, as we have asked that you do not copy other departments or individuals within the organisation into your correspondence, and you continue to do so, we are now taking the necessary steps to restrict your contact with us by email. This is not something that we wanted to do. However, we have warned you multiple times regarding this matter, yet the issue persists. The option of sending correspondence by post will still be available to you. Moreover, as we have dealt with an unreasonable volume of calls from you of late, we are also looking at restricting your calls to us to only once a week. This decision will be communicated to you by Lucas in due course.”
“I am emailing you today as your Nominated Individual (NI) regarding your recent contact with the IOPC. I have issued you with a number of warnings relating to your contact with the IOPC; specifically your continued correspondence sent directly to our Interim Director General Tom Whiting. I advised you to only contact the IOPC using this email address (enquiries@policeconduct.gov.uk) via email on 18 and20 July 2023 , as well as on the telephone on20 July 2023 . Further warnings of a similar nature were issued by the IOPC Complaints and Feedback department and by my manager, Jonathan Manning; both of these were also issued in writing via email. Despite this, you have not adhered to these warnings and you have chosen to continue to circumvent the usual contact methods and email Tom Whiting directly. As you have ignored all warnings you have been given, we have no choice but to restrict your email contact with the IOPC. You will no longer be able to contact the IOPC via email as your email address is now blocked; any additional email addresses you use to contact us will also be blocked. The system will still be open to you via online form and by post. Additionally, due to the excessive amount of time you have spent telephoning the IOPC in recent weeks, we have taken the decision to also restrict your telephone contact; you call the IOPC once a week only. I will continue as your NI and will speak to you on this one occasion should you require to phone the IOPC on that particular week. Furthermore any request to speak to any other department within the IPC will need to come through me exclusively on your allocated contact day. Please note that if you phone us more than once a week the call will be terminated and we will look to restrict you further. Please be advised that this was not a step we wanted to take, but due to your excessive recent contact, it was necessary to take this course of action.”
“…. I phoned you earlier to take your review request over the telephone. I advised beforehand that the call would be transcribed so I needed the information to be succinct and related only to your review request. The call did not go as planned so I eventually terminated as I would not have been able to get the call transcribed as it was and it did not relate to your review. I stated that I would phone you to attempt to take your review request again tomorrow. However, since our phone call, you have twice confirmed your request for review in writing, in emails at 12.40 and 12.56; therefore I will not be calling you to take a further telephone review request …..”
“Lucas has lied and decided an email complaint sent by my son on my behalf whilst he was with me is my review. Unless I say this is my review it is not my review. I have a serious heart condition and I believe Lucas is deliberately causing me harm by shouting over me causing me severe stress and anxiety. He is aware of my heart condition and that I am grieving….”