Attachment
EXECUTIVE SUMMARY
— On 9 June 2004 Chief Constable Peter
Neyroud commissioned a review of the practices and procedures
adopted by Thames Valley Police in connection with the fatal shootings
at Highmoor Cross on Sunday 6 June 2004. The Independent Police
Complaints Commission agreed to oversee this review in the interests
of public confidence.
— The purpose of the review was to
address public concern about the police response: that it took
too long for the police to get to the scene and to get urgent
medical help to the victims.
— The review concludes that the delay
in attending the scene cannot be justified.
— The reasons for the delay are not
due to the failings of the individuals involved in the response.
The failings are embedded in Thames Valley Police policy and training
in responding to firearms incidents.
— Essentially, current policy seeks
to eliminate risk rather than manage it. The direct result of
this was that the police priority in response to the emergency
calls was to locate the offender rather than get to the victims,
and an overly cautious approach to the deployment of armed officers.
— This report recommends that the policy
in relation to spontaneous firearms incidents needs to be replaced.
The new policy must provide clear direction and guidance on dynamic
risk assessment, to respond to situations where people are believed
to be hurt. It should include a presumption that unless there
are good reasons for not doing so, the command function must take
place near the scene. These policies need to be supported by new
and better training.
— The review also identifies national
issues for firearms policy and training. The IPCC will take these
up with the Association of Chief Police Officers to seek to ensure
that lessons can be learned at all levels as a result of this
tragedy.
THE REVIEW
1. Introduction
1.1 On 9 June 2004 Chief Constable Peter
Neyroud commissioned a review of the practices and procedures
adopted by Thames Valley Police in connection with the fatal shootings
at Highmoor Cross on Sunday 6 June 2004, to facilitate organisational
learning.
1.2 The terms of reference were:
— To examine and assess the effectiveness
of Thames Valley Police's policies and procedures in relation
to its response to firearms incidents
— Using appropriate methodology, skills
and analytical tools critically review the widest possible perspective
of the police action taken in response to the incident that resulted
in the deaths of Vicky Horgan and Emma Walton
— In particular to assess the effectiveness
of Thames Valley Police's initial response, command of the incident
and our joint working with the Ambulance Service
1.3 Document the findings and recommendations
within a report to be submitted to the Chief Constable for oversight
by the Independent Police Complaints Commission (IPCC).
1.4 At the invitation of the Chief Constable
the review was overseen by Deborah Glass, Commissioner of the
Independent Police Complaints Commission.
1.5 Command and Control logs, transcripts
of radio transmissions, telephone conversations and policy logs
have all been thoroughly examined, and all key personnel have
been interviewed.
1.6 A number of structured debriefs were
conducted involving staff from Police Area, Abingdon Control Room,
the Tactical Firearms Unit and Southern Oxfordshire's Multi-Agency
Public Protection Panel.
1.7 Expert opinion was sought, both internally
and externally to Thames Valley Police, with regards to firearms
tactics, firearms training, firearms policy and firearms command
protocols. The views expressed by all of those consulted are consistent
with the findings of this review.
1.8 Deputy Chief Constable Joe Edwards (Sussex
Police) and his staff have provided invaluable assistance and
guidance in relation to all aspects of this review.
2. Sequence of events on 6 June 2004
2.1 On the afternoon of Sunday 6 June 2004
the victims Vicky Horgan (deceased), her sister Emma Walton (deceased)
and their mother (seriously wounded) were at a family barbeque
in the rear garden of Vicky's home address in Highmoor Cross,
Henley. Also present were Vicky's two daughters, aged 7 and 4,
and a family friend Gemma Hunter.
2.2 Stuart Horgan, the estranged husband
of Vicky, had a long history of domestic abuse towards his wife.
The Police were involved on numerous occasions over a considerable
period of time. Horgan was arrested on 30 May 2004 for criminally
damaging Vicky's car and drink driving. At the time of the incident
on 6 June he was subject of bail conditions not to contact Vicky,
nor to attend where she lived.
2.3 Horgan had also been registered as a
dangerous offender and was the subject of the Multi-Agency Public
Protection Panel Arrangements whose risk was managed through the
Multi-Agency Risk Management process. This review will not examine
these issues, which have been considered elsewhere by Thames Valley
Police.
2.4 Approximately 4.35pm Stuart Horgan,
who had been drinking heavily, breached his bail. He climbed over
a fence into the rear garden where the barbeque was in progress.
He was armed with a .410 single-barrelled shotgun. He immediately
shot Vicky's mother in the stomach. Vicky ran indoors and Emma
ran into the corner of the garden, having grabbed both children.
Horgan immediately followed Vicky into the house but, according
to witness reports, no shots were heard.
2.5 A few seconds later Horgan returned
to the garden and shot Emma in the back. She had been trying to
phone the police on her mobile phone. Emma staggered across to
Gemma and gave her the phone but after being threatened by Horgan
she put the phone down. Stuart Horgan returned to the house where
he shot Vicky in the head.
2.6 Horgan then left the scene, still armed,
and walked towards the general direction of Nettlebed. He was
arrested later that evening in Peterborough still in possession
of the .410 shotgun.
2.7 Vicky Horgan was certified dead at the
scene and Emma Walton died later that day in the Royal Berkshire
Hospital. Dr Chapman, Home Office Pathologist, has stated Vicky
would not have survived from the injury she sustained and it was
highly unlikely that Emma would have survived had she received
specialist medical attention. He is unable to discount the fact
that had a surgeon with the necessary specialist skills and resources
(organ available for transplant) been available then there was
the slimmest of possibilities that her life could have been saved.
Their mother was seriously wounded but survived. She continues
to make good progress.
2.8 Stuart Horgan was found dead whilst
on remand in prison. His death is subject to a separate investigation
being carried out by the Prison Authorities.
3. Police response
3.1 At 4.37pm two 999 calls were made to
the police informing them of the shooting. It was very quickly
identified that Stuart Horgan was the suspect and that he was
in possession of a "rifle". He had left the scene of
the attack but was thought to be in the area. He was last seen
walking in the direction of Nettlebed.
3.2 At 4.39pm the Control Room Inspector
took command of the incident and ordered that no officer attend
the scene. The Ambulance Service was also contacted immediately.
3.3 Over the next few minutes the Control
Room alerted Armed Response Vehicles, dispatched the force helicopter
and informed the duty Silver Commander. Approximately 25 minutes
later contact was made with the Tactical Firearms Advisor and
duty Gold Commander.
3.4 An initial rendezvous point at Henley
Police Station was chosen which was later changed to Emmer Green.
3.5 At 5.41pm armed police enter the house
and immediately call for the ambulance and paramedics to attend
(64 minutes after initial report).
3.6 At 6.04pm ambulances and paramedics
arrive at the scene (87 minutes after initial call).
4. Public concern over police response
4.1 During the time period between the report
of the incident and police attendance, local residents were left
to attend to the victims of the shooting. Georgina Gibson tended
to all three victims, attempting to stem the flow of blood and
provide first aid as best she could. Her husband, Roy Gibson,
provided the Police with a telephone commentary after attending
the scene armed with a piece of wood.
4.2 Dawn Clarke, who made the initial call,
provided the police with a commentary for approximately 70 minutes,
whilst looking after one of Vicky's children. During this time
she demanded police and ambulance attendance in excess of 50 times.
She was repeatedly told that the police/ambulance would be with
her within minutes.
4.3 Roy Gibson, Georgina Gibson and Dawn
Clarke have been highly critical of the police for the way in
which this tragedy was dealt with. From their perspective it is
the following questions and observations that require serious
consideration and explanation:
— Would Emma have died had the police
and ambulance responded earlier?
— How can the police justify not coming
to the aid of members of the public?
— Why were armed officers not sent
to protect the public at the scene whilst the search for the suspect
took place?
— Why wasn't an ambulance sent under
armed guard to tend to the victims immediately?
— Did the police prevent the ambulance
from attending?
— Why wasn't any first aid advice given
over the phone?
— Why did the police lie by continually
saying, "We are on our way"?
— Why wasn't someone in charge at Highmoor
Cross?
— Why did officers not appear to have
any local knowledge?
— Why were the children not attended
to by anyone with medical experience?
— Why was there no acknowledgment of
the actions taken by neighbours at the scene?
4.4 The incident itself and public outcry
attracted a great deal of media interest and a vast amount of
criticism being directed at Thames Valley Police. The main thrust
of the criticism was the failure of the police to attend the scene
of a crime where people had been shot and were in need of urgent
medical assistance. No justification could be seen for armed officers
not being sent to assist the victims and the residents of Highmoor
Cross.
5. Investigation summary
5.1 Having interviewed all key personnel
involved in this incident, this review has identified many areas
of weakness in Thames Valley's response to firearms incidents.
Most of these were in the process of being addressed at the time
of this incident.
5.2 All of those directly involved genuinely
believed that the decisions that they had made were in accordance
with the ACPO Manual of Guidance on the Police Use of Firearms
(ACPO Manual), Thames Valley firearms policy (Operation Saladin)
and the training that they had received. As a consequence of this,
the issues facing Thames Valley Police extend further than the
decisions made on 6 June 2004. The Force is facing a fundamental
challenge to the way in which these incidents are responded to.
5.3 There are two crucial elements at the
heart of the delay in attendance at Highmoor Cross: Command and
Policy. These have been reviewed in turn to explore potential
organisational learning with a view to shaping the way that firearms
incidents are responded to in the future.
6. Review of command
6.1 A number of factors significantly impacted
on Thames Valley's ability to take effective command of the situation
from the time of initial call through to the time that paramedics
tended to the victims.
6.2 The force when operating "normally"
relies upon an Inspector, with additional command training to
take initial control of significant incidents until such time
as a fully formed command structure can be applied. In respect
of firearms incidents, the aspirational command structure would
be achieved through an on duty Firearms Silver Cadre Officer,
and the duty ACPO officer, taking Silver and Gold respectively,
which should be implemented as soon as practicable. Spontaneous
firearms incidents are now a predictable occurrence. It follows
that the command response should be capable of coping with such
incidents, which are often ambiguous in nature and difficult to
control in the early stages.
6.3 The structure within the Control Room
(Abingdon) is adequate for the vast majority of routine and emergency
calls but it cannot and did not cope with a fast-moving critical
incident of this magnitude. This is currently being addressed
as a matter of urgency.
6.4 The Control Room Inspector took command
very early and retained that command for three hours. At the time
of the report of the shootings the structure of the Control Room
was such that the Inspector was unable to capture all relevant
information, analyse it, conduct a risk assessment and then make
command decisions. This was due to the number of functions he
had to carry out, in addition to briefing other key personnel,
as well as the technical limitations in the Control Room. The
Inspector can only effectively monitor one radio channel but three
were in operation during the crucial stages of this incident.
(In future it will be possible to more effectively patch (join)
across county boundaries but this is dependent on a national upgrade
to the Airwave radio system). Valuable information was also missed
as there was no facility to show the video images from the helicopter
in the Control Room. There is then a tendency to delay decision
making until a clearer picture emerges.
6.5 He made the initial policy decision
not to deploy any officer to the scene as it was "not safe".
The rationale for the decision not to deploy direct to the vicinity
of the scene was that there was a "need to protect all involved
in the incident". The offender was armed with a rifle and
was thought to be still in the area. He said that his decision
making was in line with policy and in accordance with all the
firearms command training that he had received.
6.6 It is the responsibility of the police
to safeguard the public. While there is no hierarchy of right
to life, protection of the public (specifically and generally)
is the priority in every spontaneous firearms incident. The Police
Service cannot be reckless in its response to such incidents—but
it must respond. Well trained and equipped firearms officers,
such as Thames Valley Police Armed Response Vehicle crews, are
available to provide a prompt response, well within the margins
of acceptable risk. Thus the decision not to deploy armed officers
to the vicinity of the scene (forward control point) as quickly
as possible was wrong. Furthermore, it remained unchallenged for
approximately 35 minutes (and took a further 26 minutes to implement
the correct command decision).
6.7 It appears that when faced with a serious
firearms threat, Thames Valley Police relies upon process. Coupled
with a lack of clarity over authority to act, this compounded
the difficulties faced in the early stages of the incident.
6.8 The officer has stated that it was never
a consideration to deploy armed officers close to the scene and
felt that he would have been criticised had he done so. He is
unaware of any training scenario where the recommendation was
for armed officers to deploy in this manner.
6.9 The reason for making Armed Response
Vehicles available is to urgently reduce risk to the public and
unarmed colleagues when facing threats. To then create a process
whereby they can never be immediately deployed appears perverse.
It is possible that the fear of using undue force may be constraining
the proper controlled use of Armed Response Vehicles.
6.10 The Duty Silver Commander was briefed
at 4.46pm. He was told that no police officers had been deployed
to the scene. He immediately made for Three Mile Cross Roads Policing
Base in order to brief himself from Command and Control. As stated,
full transfer of command did not occur for approximately three
hours. Whilst the Manual of Guidance counsels against taking command
too early, there must be an expectation if on duty for that very
purpose, to accept responsibility for the actions of the Inspector
and add value to the force response.
6.11 By 4.59pm (22 minutes after the initial
report) it was reasonably evident that Stuart Horgan was no longer
at the scene, nor in the vicinity. Although there could be no
guarantee that this was the case, the evidence from witnesses
and the helicopter was such that it should have heavily influenced
the decision to deploy armed officers at that time. It was clear
that people were in the street talking and using mobile phones.
Vehicles were also regularly passing the scene in both directions.
6.12 Given that the roads were still open,
the public wandering unprotected, repeated pleas for assistance,
and several recorded reports that the offender had left the scene,
police resources should have been sent forward.
6.13 The Tactical Firearms Advisor was contacted
at 5.03pm. He gave advice that the priority was to identify and
locate the offender by the safest possible means. He also agreed
to call out the 2nd tier response.
6.14 The role of the Tactical Advisor was
not clear. The Tactical Advisor should have been given the strategy,
threat assessment, and desired outcome, from which to suggest
viable tactical options. Had this happened, the priority would
rightly have been placed upon the victims first, search for offender
second.
6.15 At 5.05pm the second Armed Response
Vehicle arrived at the first rendezvous point, Henley Police Station,
which is 3.9 miles from Highmoor Cross. There did not appear to
be any control over where to locate the rendezvous point and determining
a suitable location resulted in some confusion with some units
being unaware that the location had changed.
6.16 There appears to be confusion around
the use of rendezvous points. This appears to have been set as
a place for resources to hold, rather than as would be expected,
a place for additional staff to meet, brief and move forward to
a scene. The choice of location, management of the rendezvous
point, confusion over which premises were in use and extreme distance
from the scene caused real problems in the resolution.
6.17 The first Ambulance crew went direct
to the "old" Henley Police Station, unaware of the existence
of the new station. They arrived at the rendezvous point at 5.05pm.
This confusion was exacerbated by the fact the police and ambulance
have different radio systems.
6.18 It was then acknowledged that this
location was not suitable, and the rendezvous point moved to Emmer
Green, which is 5.2 miles from the scene, but crucially eight
miles from the first rendezvous point. Both rendezvous points
were clearly unsuitable as they were too far from the scene. A
holding point near to the scene but in the opposite direction
to which the suspect was last seen walking would have been preferable.
6.19 The Duty Gold Commander was briefed
at 5.07pm and offered Gold support. The Gold Commander was satisfied
that this was a silver-led spontaneous firearms incident. Other
officers concurred that there was no role for Gold to play whilst
the incident was "live".
6.20 At 5.15pm the Duty Detective Sergeant
for Southern Oxfordshire on his own initiative went in his own
vehicle to the scene. He confirms the fact that people were in
the street and that the offender did not appear to be present.
He had also travelled from Nettlebed and had not seen the offender.
He provided a situation report to the Control Room.
6.21 His information appears to have been
the catalyst for the eventual deployment of officers to the scene.
The officer appears to have carried out the actions which should
have been ordered at the outset. The information in his possession
when he moved to the vicinity of the house was no better than
when the incident was first reported. His personal safety was
in no more jeopardy than the general public. His initiative was
correct, but he should have been doing so on behalf of the commander.
6.22 After this situation report was provided,
it was decided that an ARV crew and Ambulance crew would both
be deployed to the scene; however the choice of rendezvous points
and the subsequent change of location built in a considerable
delay in actually getting them there. It appeared that the priority
was to go to the rendezvous point rather than to go direct to
Highmoor Cross. It was entirely predictable that at some stage
an approach would be made to the address. It was also predictable
that it may have to be carried out quickly. To allow resources
to remain at remote holding points created significant delay.
6.23 At 5.38pm the second Armed Response
Vehicle was deployed to the scene. At the same time, the first
Ambulance crew arrived at the Emmer Green rendezvous point. A
further Armed Response Vehicle was also making its way directly
to the rendezvous point but was experiencing engine problems that
limited its speed to 50mph.
6.24 At 5.41pm armed police entered the
premises having made a tactical approach. They demanded that paramedics
attend the scene immediately.
6.25 At 5.45pm the Ambulance crew initially
refused to attend the scene as the police could not confirm that
the offender had been located and the area was safe. Several minutes
later they agreed to attend with an armed escort. Providing additional
armed support also built in a delay to the Ambulance crew attending.
Given the confusion, lack of clarity and actions taken up to that
point, a reticence by ambulance staff to move forward is entirely
understandable. Had all units been holding together near to the
scene, properly briefed by a scene commander, with clear contingency
plans in place, this would not have occurred.
6.26 It is difficult to establish the change
in circumstances that resulted in the decision to deploy to the
scene. The information that was available at the moment of deployment
had been available within several minutes of the initial call.
Procrastination rather than events appear to have dictated tactics.
6.27 The operators' initial reaction to
the calls was that the emergency services would be deployed direct
to the scene to attend to the victims, a message they conveyed
to the callers. As part of their training they are instructed
to keep callers on the line in order to obtain up to date information.
During these lengthy calls the operators did their best to provide
information and reassurance to the caller. They did not know what
the tactical plan was or when it was to be implemented. They provided
estimates in the honest belief that the emergency services would
be deployed "without delay".
7. Review of policy
7.1 The Gold, Silver and Bronze system identifies
three command levels, strategic, tactical and operational, through
which an operation is controlled and accountability maintained.
In very basic terms Gold determines strategy (what to do), Silver
determines tactics (how to do it) and Bronze implements the plan
(does it). This structure will not fall into place immediately
on the report of an incident but it will be something that the
person taking command initially (usually the Control Room Inspector)
will strive to implement as quickly as possible.
7.2 All officers involved in making command
decisions or influencing them have stated that their decisions
were in accordance with the ACPO manual. The manual's guidance
suggests that Control Room Inspectors will take initial responsibility
for command until such time that it is transferred to a more senior
officer.
7.3 It is important to note that in relation
to the transfer of command it states:
— It should not be assumed that a trained
Silver Commander will immediately take on that role upon being
contacted as their ability to perform an effective Command function
depends upon:
— Knowledge of all intelligence / circumstances;
— Ability to communicate;
— Availability of appropriate tactical
advice;
— Being suitably located;
— The transfer of such roles should
take place as soon as practicable in accordance with Force procedures.
7.4 Thames Valley Police would appear to
have interpreted this guidance to mean command will not transfer
until all four elements of this section have been satisfied to
a very high degree. This will inevitably cause considerable delay
in transferring command and have an impact on actions taken on
the ground. In this case the transfer of command did not take
place for three hours, which is unacceptable.
7.5 Thames Valley's firearms Commanders,
supported through the "in force" training they receive,
have interpreted this section of the manual as meaning that the
Commander must have access to Command and Control in order to
read the log, have access to their own operators and be suitably
located where they can access all of this before they will allow
transfer of command to take place.
7.6 Other forces, not all, interpret this
section as meaning that the Commander must be verbally briefed,
in a position to communicate via their mobile phone, in a location
where they can effectively communicate and in a position to speak
to a Tactical Firearms Advisor. Clearly this is a more fluid interpretation
of the guidance.
7.7 The ACPO manual tends to support Thames
Valley's approach to dealing with firearms incidents, however
the ambiguity causes inconsistencies in the national approach.
7.8 Transfer of command should ideally take
place as soon as a Commander has been briefed and he/she is in
a position to effectively communicate with others. This is likely
to be when they are in the office, at home or in their vehicle.
They will obviously make plans to move to a more suitable location,
ideally to the scene, and may have to transfer command back if
they are unable to effectively communicate on that journey.
7.9 The initial information will almost
inevitably be vague and confusing but this is even more reason
for command to transfer to the most appropriate person as quickly
as possible. A dynamic risk assessment must be carried out based
on the information and intelligence available at that time. It
may be that a different picture emerges later on, requiring a
reassessment, but this is no reason to delay crucial command decisions
being made. Risk assessment is a continual process but waiting
to have a "full" picture is not an option when our priority,
as it was at Highmoor Cross, was to protect the public and attend
to the victims.
7.10 Operation Saladin, Thames Valley's
policy for dealing with firearms incidents, is a satisfactory
process for dealing with pre-planned operations or events that
are prolonged and therefore need a wide range of services and
support. It is inadequate as a policy to deal with spontaneous
firearms incidents. It can build unnecessary delays into incidents
which require immediate firearms deployment (and where intelligence
can be gleaned from those deployments). The policy attempts to
eliminate risk rather than manage it.
7.11 Thames Valley Police's "strategic
aim" in all firearms situations, which is stated in Operation
Saladin, is always standard:—
Minimise injuries to all persons;
Prevent the subject from causing harm;
Use no more force than is absolutely necessary;
This may best be achieved by identifying, locating
and containing the subject thereby neutralising the threat posed.
7.12 As this declared strategic aim is "standard"
there is a tendency not to articulate what the aim is during a
specific firearms operation. It is also one of the reasons that
the concentration was put solely on locating the suspect and insufficient
consideration given to the victims who had been shot. This would
have been totally justified had Horgan been sighted or located.
The priority would clearly have been to neutralise the threat
of further loss of life and injury.
7.13 The Saladin process is aimed at providing
an effective decision making forum and a consistency of approach
across the force. The policy states that the Saladin process normally
starts as an incident moves from spontaneous into pre-planned
but that its principles should be applied to all firearms incidents.
There is a culture within Thames Valley to manage firearms incidents
as if they were pre-planned when clearly there are occasions for
which this process is not appropriate.
8. Conclusion
8.1 After comprehensively reviewing all
of the evidence in relation to the shooting at Highmoor Cross,
this report concludes that the level of delay in both the Police
and Ambulance Service attending the scene cannot be justified.
The Police have a basic duty to preserve and protect life.
8.2 The staff involved in the decision making
process are very dedicated and committed professionals. There
is no evidence to support any charges of discipline or misconduct.
The weaknesses identified in this review in relation to how the
incident at Highmoor Cross was dealt with are fundamental issues
for Thames Valley Police and possibly the police service nationally.
8.3 The initial command decision not to
deploy any resources to the scene was wrong. The emerging picture
should have reinforced the need to send officers to the area.
There is little doubt that the initial response fell into a structured
routine of finding rendezvous points, briefing commanders, obtaining
tactical advice and setting up a command suite, but did not provide
an adequate response to a situation in which the public urgently
required immediate assistance from the police.
8.4 The priority for the Commander was clearly
to identify, locate and contain the offender. The decision to
change the priority from the offender to the victims should have
been made at 4.59pm at the very latest (22 minutes after first
report). This was the time that a dynamic risk and threat assessment,
if carried out, would have identified that the likelihood of the
suspect being in the area was slim.
8.5 A Bronze Firearms Commander was available
and in a position to respond. He should have been deployed to
a suitable location near to the scene of the crime where he could
have and performed the role of Ground Commander, a role which
his function dictates. He was not utilised appropriately.
8.6 The correct decision to deploy armed
resources was made at 5.15pm but the transfer of rendezvous points
from Henley Police Station to Emmer Green (eight miles apart)
built in a further 25 minute delay for both the Police and Ambulance
Service. There appeared to be a lack of faith in the ability of
the Armed Response Vehicle staff to act within their training.
If that is because the Armed Response Vehicle staff are not trained
sufficiently to tactically deploy to get observations on an address,
then contain any threat posed, that should be addressed. If there
is a fear of undue force being applied by them, then that should
be explored and addressed by their commanders.
8.7 At 5.41pm armed police officers arrived
at Highmoor Cross and secured the scene. The Ambulance Service
refused to attend at this time due to the fact that the whereabouts
of the suspect were unknown. The Ambulance Service should have
deployed their resources on the advice of the Police. This decision
built in a further delay of 14 minutes which could have been avoided
through effective scene control.
8.8 Command of this very serious incident
should have transferred from the Control Room Inspector to a Silver
Commander as quickly as possible. On 6 June this took three hours.
The primary reason at the core of this delay is Thames Valley's
interpretation of the ACPO Manual of Guidance on the Police Use
of Firearms, which has been embraced within Thames Valley's Operation
Saladin Policy.
8.9 The wording used in the ACPO Manual
in relation to the "transfer of command" can be interpreted
in a number of ways. Thames Valley Police has interpreted it in
a way that unavoidably builds in considerable delay in transferring
command of a "spontaneous or live" firearms incident
to a Silver Commander and thus increases rather than mitigates
risk.
8.10 Silver Commanders, in accordance with
guidance and their training, require themselves to be fully briefed,
have access to Command and Control and be in a suitable location,
prior to taking command. On many occasions this approach will
cause little or no problems, but it has inherent weaknesses when
dealing with a critical incident that requires a dynamic risk
assessment and an early transfer of command.
8.11 Tactical Firearms Advisors are there
to provide expert advice on how to tactically resolve a firearms
incident. Silver Commanders, prior to contacting the Tactical
Advisor, should have made an assessment of the situation, decided
what the strategic aim is and formulated a policy in relation
to what needs to be achieved. Advice can then be sought in relation
to appropriate tactics needed to achieve the aim. All too frequently,
as was the case at Highmoor Cross, Tactical Advisors are being
asked to provide advice in relation to command decisions. They,
in effect, become the Commander or at best the role of Commander
is blurred.
8.12 Thames Valley Police have made considerable
progress in relation to how they resource and deal with firearms
incidents. The Chief Constable, having identified this as a priority,
has invested greatly in the provision of more resources to respond
to incidents throughout the Force area. He has also introduced
a Firearms Cadre which ensures that fully trained and accredited
Silver Commanders are available at times that demand has dictated.
Although in its infancy, this system was in place on 6 June and
contributed to a Silver Commander being on duty at the time. When
fully functional it will have the capacity to take early command
of spontaneous incidents from the scene of the incident.
8.13 Vast improvements have also been made
in the development of highly sophisticated computer and video-based
software, which is used to train all Firearms Commanders. There
is a need to ensure that Gold, Silver, Bronze, and Tactical Advisors
training is provided within a common programme to ensure consistency
of approach across all the roles, and provide a single interpretation
of guidance and policy.
8.14 All of these improvements will reduce
the likelihood of this occurring in the future but only if it
is combined with a change in culture in how Thames Valley Police
makes decisions. This review is not advocating that that all firearms
incidents are attended immediately, this would be irresponsible
and reckless, but Thames Valley Police would appear to have excluded
it as an option, which can expose the public and unarmed colleagues
to risks which could be more safely mitigated against.
8.15 The causal factors of the criticisms
levelled at Thames Valley Police appear to be procedural rather
than "human error". All personnel involved believed
that they had acted in accordance with the ACPO Manual and Operation
Saladin. This indicates weaknesses in policies, training and consequently
practice that Thames Valley must accept and address in order to
learn the lessons from the tragic events that day. Every effort
must be taken to prevent the same situation occurring in the future.
8.16 Valuable lessons are being missed,
both at a force level and nationally, due to ineffective debriefing
and dissemination of learning from firearms incidents. There is
a tendency not to thoroughly de-brief firearms incidents which
have resulted in a successful outcome, despite the fact that there
may have been weaknesses in the way they were handled. There is
also no national database where forces can learn from each other.
9. Recommendations
For Thames Valley Police:
9.1 Operation Saladin should be withdrawn
and replaced with a new policy to provide clear guidance to commanders
dealing with spontaneous firearms incidents, especially where
people have been, or are suspected to have been injured. The policy
must highlight the roles and responsibilities of commanders and
also provide clear guidance in relation to the transfer of command.
It should also stipulate that the command function must, unless
there are good reasons for not doing so, be performed near to
the scene of the incident. Policy and training needs to provide
clear direction and guidance to all firearms commanders in relation
to dynamic risk and threat assessing and the making of command
decisions under extreme pressure and with limited information
or intelligence.
9.2 Firearms training for commanders needs
to be co-ordinated across all roles to ensure a consistent interpretation
of policy and guidance.
9.3 Establish a Head of Profession to lead
and provide consistency within force and to take responsibility
for police development and training.
9.4 Technology support in the command and
control environment needs to be reviewed urgently to ensure that
it is fit for purpose.
9.5 Joint training should take place between
Thames Valley Police and the Ambulance Service in order to enhance
communication, decision making and command protocols. This recommendation
has been welcomed by Royal Berkshire Ambulance Service. The issue
of joint control rooms and radio systems should also be pursued.
National
9.6 The ACPO Manual of Guidance on the Police
Use of Firearms needs to be amended in relation to the "transfer
of command" during a spontaneous firearms incident. It needs
to provide clear and unequivocal guidance on the role of a Silver
and Gold Commander, when they should be informed of a firearms
incident and what is expected of them in the early stages of an
incident. This should be supported by consistent standards in
command training.
9.7 Findings from de-briefings of all serious
firearms incidents should be disseminated for the benefit of all
Commanders and also be used to influence how the police train.
This must be a robust process where both best practice and poor
practice can be highlighted. Development of a national database
of such incidents would greatly assist individual force training
and development.
Michael Tighe
Detective Superintendent, Professional Standards
Department
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