Date of report: 13/02/2023
Deceased name: Hannah Warren
Coroner name: Edward Ramsay
Coroner Area: Swansea Neath Port Talbot
Category: Other related deaths
This report is being sent to: Metropolis, Home Office, College of Policing and National Police Chief’s Council
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS|
|THIS REPORT IS BEING SENT TO: (COMMISSIONER OF THE POLICE OF THE METROPOLIS)
THE Rt HON SUELLA BRAVERMAN KC MP (SECRETARY OF STATE FOR THE HOME DEPARTMENT)
CHIEF EXECUTIVE, COLLEGE OF POLICING (CHAIR, NATIONAL POLICE CHIEF’S COUNCIL)
I am EDWARD RAMSAY, His Majesty’s Assistant Coroner for the coroner area of SWANSEA NEATH PORT TALBOT.
|2||CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.|
|3||INVESTIGATION and INQUEST
On 15 FEBRUARY 2016 the Senior Coroner commenced an investigation into the death of HANNAH WARREN aged 28 (hereafter “Hannah”). The investigation concluded at the end of the inquest held between 16-26 JANUARY 2023. The conclusion of the inquest jury was that Hannah died as a result of 1(a) drowning 1(b) head injury, and they returned a narrative conclusion in the following terms:
|4||CIRCUMSTANCES OF THE DEATH
In the evening of 3 February 2016 Hannah was reported missing by her flat mate and fiancé. The report was made to the MPS. It appeared Hannah had left London in her motorcar shortly after 11am that morning and had not been spoken to since around 10.30am.It was reported that she had been acting out of character expressing delusional thoughts and ideas, specifically that she “hacked into a computer” and the “government were after her”.Hannah’s case was considered by the Duty Inspector at Brixton police station towards the end of his shift that evening. He assessed Hannah as “medium risk” using the COMPACT risk assessment tool.
(4) A LOW stop ACT was placed on Hannah’s vehicle on the Police National Computer by the investigating Police Constable. There was no specific instruction to place a Low ACT (as opposed to a Medium / High stop ACT) and no discussion about which priority to place on the said ACT. The available evidence established that ‘LOW’ would probably have been placed on the ACT by default.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
|6||ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by MONDAY 10 APRIL 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
|8||COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
(1) Hannah’s Family
(2) Metropolitan Police Service
(4) Associated British Ports
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.
|9||13 February 2023 EDWARD RAMSAY ASSISTANT CORONER FOR SWANSEA NEATH PORT TALBOT|
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