PFD report

Chelsie Violet Greatorex · Prevention of Future Deaths report

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Issued 12 Nov 2020•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Delays in contacting complainants seeking support
    Part of recurring concern: Unreliable communication access for people requiring support
  2. Inadequate support for complainants seeking assistance
  3. Failure to conduct child sexual assault investigations through a specialist officer or team
    Part of recurring concern: Unsafe investigation of child sexual assault allegations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Trial and roll out the THRIVE+ vulnerability assessment framework for assessing and reviewing victim and witness risk.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2021.
  2. Action

    Introduce the vulnerability tool into monthly Offender Management Meetings to identify and prioritise vulnerable-victim cases requiring management intervention.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2021.
  3. Action

    Operate the North East Basic Command Unit Response Support Team as a training and investigative advice resource for response officers.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    There was little indication that the complainant was very low or required support beyond what would normally be considered for a complainant facing trial.

    Stated by Metropolitan Police ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in contacting complainants seeking support

Wider context from the report

“d. When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of a borough psychological support service. ”

Is this part of a recurring concern?

Yes — Unreliable communication access for people requiring support.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate support for complainants seeking assistance

Wider context from the report

“d. When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of a borough psychological support service. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to conduct child sexual assault investigations through a specialist officer or team

Wider context from the report

“b. Despite the fact that Ms Greatorex was a child when the events of the allegation took place, the investigation was not conducted by a specialist officer or team. ”

Is this part of a recurring concern?

Yes — Unsafe investigation of child sexual assault allegations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in investigation and progression of sexual assault cases

Wider context from the report

“c. Delays in the investigation were identified, • despite naming the suspect and their place of study, no interview took place for over 3 months. • a decision to prosecute was not arrived at until late December 2020. • A court hearing was not listed until January 2020. ”

Is this part of a recurring concern?

Yes — Unreliable police handling of reported sexual assault allegations.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Trial and roll out the THRIVE+ vulnerability assessment framework for assessing and reviewing victim and witness risk.

Verbatim wording from the response

“In order to provide additional support for victims and/or witnesses throughout the entire investigative process, the MPS has introduced a THRIVE+ vulnerability assessment which is currently being trialled and is anticipated to be rolled out across the MPS in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool which aligns to and enhances the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 2 · response
Published 27 January 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce the vulnerability tool into monthly Offender Management Meetings to identify and prioritise vulnerable-victim cases requiring management intervention.

Verbatim wording from the response

“The observations about the length of the investigation and failure of management systems to adequately prioritise Ms Greatorex’s case are being addressed with the introduction of a new product, the vulnerability tool, which has been developed for Basic Command Units’ monthly Offender Management Meetings which prioritise outstanding named suspect cases when the victim has been identified as being the subject of some form of vulnerability. This allows for management intervention and looks across all offence types to identify cases where progress should be prioritised for the benefit of victims where an element of vulnerability has been identified.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate the North East Basic Command Unit Response Support Team as a training and investigative advice resource for response officers.

Verbatim wording from the response

“The MPS recognises that as the investigation was not considered complex, it should have been completed in a quicker timeframe. The MPS have therefore made improvements in the supervision and team structures of response teams to support less experienced officers with their investigations. A Response Support Team was set up on North East Basic Command Unit on 23rd September 2020 and blends together resources from Emergency Response Policing Teams, Local Resolution Teams, Criminal Investigation Departments and probationary officers and their mentors. The Response Support Team functions as a training unit and allows for a steady improvement of officers investigative skills and point of contact for advice.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish a national strategy addressing all forms of child sexual abuse.

Verbatim wording from the response

“Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, you may also wish to be aware that the government will shortly be publishing a first of its kind national strategy on tackling all forms of child sexual abuse. A key element of this strategy will be working across government to improve the way the criminal justice system responds to child sexual abuse and to ensure victims and survivors receive the support they deserve. We will continue to prioritise child sexual abuse as a national threat in the Strategic Policing Requirement, to empower police forces to maximise their specialist skills and expertise to tackle these crimes.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Invest additional annual funding through 2022 to recruit more Independent Sexual Violence Advisers.

Verbatim wording from the response

“Furthermore, the government is committed to ensuring access to high quality support for victims and survivors of rape and sexual assault, wherever they live in the country and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has awarded £12m to 91 rape support centres across England and Wales to provide independent, specialist support to victims of sexual violence, including victims of child sexual abuse, an increase of £4m from 2019/20. The government has also announced that an additional £4m per year until 2022 will be invested in recruiting more Independent Sexual Violence Advisers (ISVAs) who play a vital role in informing and supporting victims at every stage of the criminal justice process.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue prioritising child sexual abuse as a national threat in the Strategic Policing Requirement.

Verbatim wording from the response

“Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, you may also wish to be aware that the government will shortly be publishing a first of its kind national strategy on tackling all forms of child sexual abuse. A key element of this strategy will be working across government to improve the way the criminal justice system responds to child sexual abuse and to ensure victims and survivors receive the support they deserve. We will continue to prioritise child sexual abuse as a national threat in the Strategic Policing Requirement, to empower police forces to maximise their specialist skills and expertise to tackle these crimes.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Carry out a cross-system review of the criminal justice response to rape and report a package of improvement actions.

Verbatim wording from the response

“That is why, along with the Ministry of Justice and the Attorney General’s Office, the Home Office is currently carrying out a review of the criminal justice response to rape. The scope of the review covers the length of the criminal justice process, from police report and investigation through to final outcome in court, so that we can take a comprehensive view of any issues that need to be addressed within the system and take action accordingly.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 1 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consult on a Victims’ Law to guarantee victims’ rights and hold agencies accountable for delivering them.

Verbatim wording from the response

“The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Fund rape support centres across England and Wales to provide independent specialist support to victims of sexual violence.

Verbatim wording from the response

“Furthermore, the government is committed to ensuring access to high quality support for victims and survivors of rape and sexual assault, wherever they live in the country and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has awarded £12m to 91 rape support centres across England and Wales to provide independent, specialist support to victims of sexual violence, including victims of child sexual abuse, an increase of £4m from 2019/20. The government has also announced that an additional £4m per year until 2022 will be invested in recruiting more Independent Sexual Violence Advisers (ISVAs) who play a vital role in informing and supporting victims at every stage of the criminal justice process.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish a restructured Victims’ Code establishing overarching rights to support during the criminal justice process.

Verbatim wording from the response

“The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

There was little indication that the complainant was very low or required support beyond what would normally be considered for a complainant facing trial.

Verbatim wording from the response

“The DPS SIU Investigation Report details a number of occasions when Ms Greatorex reached out to the investigating officer about feeling anxious and low. They appear to have formed a trusting relationship and when Ms Greatorex appeared to become particularly low, the investigating officer offered Ms Greatorex advice and a referral to a support agency. However, Ms Greatorex reassured the investigating officer that she was fine. On the day Ms Greatorex was informed of the date of the trial, there was little to suggest to the officer that she was feeling very low or in need of any further support other than that would be normally considered during a difficult time for any complainant in a case such as this.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 1 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The timeliness of the prosecution decision and court listing lay with the Crown Prosecution Service and Her Majesty’s Courts Service.

Verbatim wording from the response

“The timeliness from when the decision to prosecute and the court hearing lies with the CPS and Her Majesty’s Courts Service (HMCS). The suspect for this allegation was interviewed on 5th November 2019 leading to a submission of the evidential file to the Crown Prosecution Service (CPS) on 26th November 2019. The investigating officer made further contact with the CPS on 18th December 2019 regarding the decision on a charging authority and seeking to expedite the case. The CPS authority was granted on 27th December 2019. The suspect was served charges on 2nd January 2020 with a first court appearance provided for the end of the month.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 3 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The allegation was considered non-complex, so specialist investigation was not required and responsibility appropriately remained with a Response Team officer.

Verbatim wording from the response

“The allegation Ms Greatorex made was considered at the outset by specialist officers and it was decided that due to the non-complex nature of the investigation, it would remain with a Response Team officer to investigate. The MPS General Investigation Policy states that “Where there is a requirement for ownership of crime investigations by the initial investigating officer, there may be occasions where the characteristics of specific investigations identify themselves as serious and/or complex. It is important that this is identified as soon as possible so that the most appropriate investigating unit is assigned to that investigation dependent on the seriousness and/or complexity. If serious and/or complex characteristics are present, then CID should be approached to take on that investigation”.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 2 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Metropolitan Police Service will respond separately on specific investigation matters because it is operationally independent.

Verbatim wording from the response

“In your letter you ask that I ensure the matters you have raised are considered by the Metropolitan Police Service. I should stress that the Metropolitan Police Service is operationally independent and, as such, will respond separately on the specifics of the investigation in question. I am therefore responding to the Coroner’s concerns only in so far as they relate to national policy.”

Source location

2021-0018-Response-from-Home-Office-Redacted
Page 1 · response
Published 27 January 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Develop and publish a Suicide Prevention Policy Document and accompanying Toolkit covering prevention information, support services, risk indicators, contacts and good practice.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2021.
  2. 2

    Develop an investigative standards document providing first responders with guidance on responding to suicide risk.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2021.
  3. 3

    Meet with other police forces to learn and share suicide-prevention good practice.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2021.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and publish a Suicide Prevention Policy Document and accompanying Toolkit covering prevention information, support services, risk indicators, contacts and good practice.

Verbatim wording from the response

“The MPS is committed to progress learning from instances of death by suicide involving victims and suspects and further develop the response to these. A small team of dedicated officers leading this work has focused on the delivery of key areas. The team is developing a Suicide Prevention Policy Document and Toolkit. The publication of this policy is a key step in developing our co-ordinated strategy to suicide prevention. The policy will draw together information on suicide prevention, support services, risk indicators, contacts and best practice. It will be accompanied by a toolkit providing easy to access guidance and advice from signposting support services to identifying key partners. A draft external Suicide Prevention Policy is due to be drafted by the end of December 2020 prior to going through the MPS’s internal policy development process.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 3 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop an investigative standards document providing first responders with guidance on responding to suicide risk.

Verbatim wording from the response

“In addition to the policy publication, the suicide prevention team is committed to improving the training and guidance available to all officers and staff. An investigative standards’ document is under development and is designed as an easy to follow key points to consider document for police first responders. This will enhance knowledge and understanding across the entire service and build on the additional guidance that is already used by some teams where death by suicide is considered higher risk i.e. Custody, Online Child Sexual Abuse.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 3 · response
Published 27 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Meet with other police forces to learn and share suicide-prevention good practice.

Verbatim wording from the response

“The MPS Suicide Prevention Team is also meeting with other police forces to learn and share good practice.”

Source location

2021-0018-Response-from-MPS-Redaction
Page 4 · response
Published 27 January 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026