Investigation and inquest
On 30th December 2016 I commenced an investigation into the death of Michaela Marie Haines who died on 23rd December 2016. The investigation concluded at the end of the inquest on 23rd November 2017. The conclusion I recorded was an open conclusion.
Circumstances of the death
(1) At approximately 02.36hrs on 23rd December 2016, police were dispatched to deal with a report of a female hanging in the stairwell of flats at Tenby Mount, Tenby.
(2) A STORM (System for Tasking and Operational Resource Management) Command and Control System incident report was created and up-dated with developments as the investigation continued.
(3) The STORM report identified the need to follow up enquiries with the occupants of persons living within the block of flats. It is not clear whether enquiries were followed up with the occupants of the block of flats as no record of such enquiries has been entered onto STORM.
(4) The STORM report further identified that CCTV covered the stairs and would show anyone approaching the stairs. Whilst there was some evidence before the inquest that this did not operate, the STORM report was not updated to confirm the position.
(5) CCTV from a local hotel was requested from the proprietors who preserved the same for police. They believe this was collected from them but it has not been entered into the property log. Had the STORM report been fully completed identifying this as a task and then recording steps taken to complete this task, then any issue as to whether this piece of evidence had been secured would have been resolved, thus avoiding the distress it caused to the family.
Coroner’s concerns
The STORM report had not been up-dated with actions taken. This caused uncertainty as to whether outstanding enquiries had been actioned or not. This may have resulted in evidence not being preserved. It could also result in work being duplicated with enquiries being made when they have already been undertaken. If the STORM report is to be used as an effective command and control document it is essential that it is updated in the light of changing developments. Training may be required to remind those using this vital work tool of the need to keep it up to date.