Mark Duggan · Prevention of Future Deaths report

16. On the evening of 4 August 2011 officers from SCD11, Trident and CO19 were due to assemble at police premises in Wood Green, code-named ‘Quicksilver.’

17. One Trident officer, known for the purposes of the Inquest as ZZ17, was in charge of handling the intelligence at the material times. On 4 August 2011 he was at Quicksilver with several Trident officers when he learned about the intended hand-over of the gun in the Vicarage Road area of Leyton. He subsequently received intelligence about that having taken place. Also, he had intelligence that Mark Duggan was thought to be going to Broadwater Farm with the gun.

18. Trident officers were able to get to the Vicarage Road area before Mark Duggan. They identified the minicab he was in when it arrived, and followed it when it left. The CO19 officers had to race to get to Quicksilver and then to get behind the minicab. They did that shortly before Ferry Lane, and they decided to conduct the stop at that point.

19. This was intended to be something formally called an enforced vehicle stop, commonly known as a “hard stop”. It involved three CO19 cars, referred to as Alpha, Bravo and Charlie, each containing three armed officers. Behind these three cars was a control car.

20. The Alpha car overtook the minicab, moved in front of it and braked sharply. The Bravo car drove alongside the offside of the minicab, to prevent it overtaking the Alpha car, and the Charlie car drove up to the rear of the minicab. As the minicab came to a halt, Mark Duggan exited the minicab onto the pavement.

21. The officers left their cars. Two of them, who gave evidence as V53 and W70, left the Charlie car, and got onto the pavement to the rear of the minicab. V53 was armed with an MP5 carbine, which is a short rifle of the kind armed police have in airports. He fired twice in quick succession. No-one else fired a gun.

22. One of the shots hit Mark Duggan on the inside of his right bicep, and did not cause a fatal wound. The other went into his chest and out of his back. That shot hit his aorta, the main artery into which the heart pumps blood. The damage to it was catastrophic and resulted in a fatal wound.

23. An officer from the Alpha car, W42, was behind Mark Duggan. One of the two shots fired by V53 travelled through Mark Duggan’s body and hit W42’s radio, worn in a holster near his left armpit.

24. At figure 1 is a photograph of the cars in place after the shooting (the Alpha car was driven onto the pavement shortly after the stop) :

25. A number of officers, but principally V53, performed first aid on Mark Duggan. They did that with conspicuous skill and care but nonetheless he was pronounced dead at the scene by a doctor.

26. The operation then came to a halt. No attempt was made to retrieve other guns from Hutchinson-Foster, who was only arrested months later.

27. Immediately after the shooting, only the officers involved in the operation were at the scene. No pistol could be found next to or underneath Mark Duggan, but officers gave evidence that they found a pistol wrapped in a sock on the grassland, the other side of the fence from Mark Duggan’s body. At figure 2 is a photograph of the gun in the sock. Figure 3 is a plan of the scene. By the stage it was compiled, a plant pot had been placed over the gun:

28. The MPS handed command of the investigation to the Independent Police Complaints Commission (“IPCC”) very shortly after the incident.

29. Initially, it was thought that the round which struck W42’s radio was a non-police issue bullet. From this it was inferred that Mark Duggan had fired it and that is what the press were told.

30. As can be seen from figure 4 a shoebox was inside the minicab. It was about one foot square. The evidence, accepted by the jury, was that Mark Duggan collected it from Mr Hutchinson-Foster, in Leyton, although the latter denied that.

31. All those police officers at the scene who saw anything relevant made notebook entries after their return to their bases. They did not give statements until 7 August 2011. Prior to making their notebook entries, the CO19 officers were seen by a doctor, a Police Federation representative and a solicitor. They were warned against conferring, but no step was taken to prevent them from doing so. On 7 August the CO19 officers sat together when writing their statements. Again, they were warned against conferring but were not prevented from doing so. This was consistent with normal practice and guidance issued by the Association of Chief Police Officers (“ACPO”).

32. The Home Office pathologist conducted the post-mortem examination of Mark Duggan. The Duggan family then commissioned a second post-mortem examination by a second pathologist.

Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.

I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.

Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity

I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw. I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements. I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation.

Concern 3: The IPCC had primacy at the scene but did not have the resources to conduct all relevant activities there

I am concerned that no scene of a fatal shooting should be the subject of any confusion about the purpose of the investigation, or about what should be done to further that investigation. There is a tension, in a case such as this, between the duty of the MPS to obtain and secure evidence at the scene, its position as being under investigation, and the IPCC’s obligation to investigate independently. The pragmatic approach adopted of the MPS consulting the IPCC about what should happen may not always resolve that tension. My primary concern is whether that position should persist. If it does then I am concerned that the police service has the practical control of many aspects of the scene and what happens there despite being under investigation, without the public realising that the investigation does not have full independence which the IPCC’s role appears to safeguard. This concern is addressed to the IPCC, the Home Secretary and the MPS.

Concern 4: The scene of the fatal police shooting was not video recorded

I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO.

Concern 5: The planned operation to seize weapons was not pursued after the fatal shot was fired

My concern is that no consideration appears to have been given to the prospect. A starting point should have been that one of the Trident officers saw the minicab turn into Burchell Road for the handover, and that was a short cul-de-sac. This concern is addressed to the MPS, the IPCC and ACPO.

Concern 6: The armed police operation was not recorded after State Red was called

I am therefore concerned that the cars involved in stopping the minicab containing Mr Duggan had data available to be downloaded or that the technology was not as effective in 2011 as it was in 2005. I expect to be told the actual position. In the circumstances I address these concerns to the MPS and ACPO.

Concern 7: The IPCC does not have a protocol agreed with the Chief Coroner, ACP and the CPS

With a view to coroners holding effective inquests as soon as practicable I address this concern to the IPCC and ask it to consider approaching the Crown Prosecution Service, the Association of Chief Police Officers, the Chief Coroner and the Coroner’s Society with a view to integrating its memorandum with theirs.

Concern 8: The IPCC and Counsel to an inquest do not have access to all intelligence

These limitations not only give rise to understandable suspicions in the minds of those not party to the intelligence but also plainly create a risk that an intelligence-led operation which results in death will not be fully investigated so that lessons may be learned. This concern is addressed to the Home Secretary.