Report of the independent external review of the IPCC investigation into the death of Sean Rigg Table of Contents Executive Summary.............................................................................................................................. 1 The cause of death .................................................................................................................................... 2 Investigation and analysis.......................................................................................................................... 3 Police conduct........................................................................................................................................... 3 Restraint.................................................................................................................................................... 3 The question of assault by the police......................................................................................................... 4 Identification of Mr Rigg............................................................................................................................ 4 Custody and care at the police station ....................................................................................................... 6 Medical care.............................................................................................................................................. 7 Call handling.............................................................................................................................................. 7 Community mental health care.................................................................................................................. 8 The jury’s narrative verdict at the Coroner’s Inquest.................................................................................. 9 The conclusions of the IPCC report .......................................................................................................... 10 The IPCC and the Rigg family.................................................................................................................... 11 IPCC independence and the role of Commissioners ................................................................................. 12 Limitations on the IPCC............................................................................................................................ 13 Securing evidence promptly .................................................................................................................... 15 The IPCC’s role......................................................................................................................................... 15 The standards to be applied by the IPCC.................................................................................................. 16 Methodology........................................................................................................................................... 16 Resources................................................................................................................................................ 17 Key Considerations and Recommendations ....................................................................................... 18 The IPCC’s role......................................................................................................................................... 18 Scope of IPCC investigations .................................................................................................................... 18 Issues for the IPCC in the light of the Coroner’s Inquest in the case of Sean Rigg...................................... 19 Critical analysis........................................................................................................................................ 19 Mental health issues................................................................................................................................ 20 Medical care in custody........................................................................................................................... 21 The duty of the police in relation to the IPCC........................................................................................... 21 IPCC and the family.................................................................................................................................. 22 IPCC methodology ................................................................................................................................... 22 Resources................................................................................................................................................ 23 I. Introduction to full report ................................................................................................................ 24 The approach of the Review .................................................................................................................... 25 II. The course of the IPCC investigation ............................................................................................ 27 The ‘Golden Hour’ ................................................................................................................................... 27 Securing the scene ............................................................................................................................... 28 Securing CAD and CCTV evidence ......................................................................................................... 29 Securing the evidence from the four police officers present at arrest .................................................... 30 Initial statements taken ....................................................................................................................... 32 Initial assessment by the IPCC on-call team .......................................................................................... 33 The first stage of the IPCC investigation: August 2008 through January 2009........................................... 34 Delays in interviewing the four police officers ....................................................................................... 34 Referral to the CPS ............................................................................................................................... 36 Interim IPCC report .............................................................................................................................. 37 The final IPCC investigation report ....................................................................................................... 37 The Coroner’s Inquest .......................................................................................................................... 39 III. Issues for the IPCC investigation.................................................................................................. 41 A. Community mental health care ........................................................................................................... 41 Short psychiatric and forensic history ................................................................................................... 42 Risk strategy in the weeks before 21 August 2008 ................................................................................ 43 Restriction options ............................................................................................................................... 44 Multi-Agency Public Protection Arrangements (MAPPA) ...................................................................... 45 Medication issues ................................................................................................................................ 46 Culturally sensitive psychiatric care ...................................................................................................... 47 999 calls from Penrose Hostel .............................................................................................................. 47 Conclusions .......................................................................................................................................... 48 B. The 999 calls........................................................................................................................................ 49 An integrated timeline of events .......................................................................................................... 50 Responses to the 999 calls ................................................................................................................... 54 Linking information .............................................................................................................................. 54 C. Identifying Mr Rigg .............................................................................................................................. 58 D. Identifying Mr Rigg as a person with mental health needs................................................................... 60 Guidance on policing and mental health issues .................................................................................... 61 Lack of sufficient clothing ..................................................................................................................... 62