Terms of reference: HMICFRS inspection following the East London Inquests touching the deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor

Published on: 17 June 2022


On 3 December 2021, Sophie Linden, Deputy Mayor for Policing and Crime requested that Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) conduct an inspection, under section 54(2BA) of the Police Act 1996. On 13 December 2021, Matt Parr, Her Majesty’s Inspector of Constabulary confirmed that HMICFRS would be willing to proceed under these statutory provisions.

Since the murders of Anthony, Gabriel, Daniel and Jack the Metropolitan Police Service (MPS) has sought to learn the lessons and make changes to prevent these tragic mistakes ever happening again. The MPS have also received the Coroner’s Prevention of Future Deaths report and the Independent Office for Police Conduct (IOPC) Learning Recommendations, to which they have submitted formal responses.

Alongside the HMICFRS inspection, there are reviews by other bodies, such as the IOPC, and a review of MPS standards and culture by Baroness Casey of Blackstock DBE CB. These are intended to provide the Commissioner and DMPC independent assurance concerning the force’s efficiency and effectiveness.


It is not the role of this inspection to highlight the failings of this tragic case – the IOPC are actively considering whether to re-open their original misconduct investigation. The inspection’s focus is on establishing whether lessons have been learnt and action taken to prevent these failings being repeated.

This inspection will, therefore, specifically focus on the current standard of death investigations, utilising HMICFRS’ professional policing knowledge and skills. It will focus on deaths within public spaces or private domestic settings, rather than those within institutions such as hospitals or care homes.

The following are the areas that the Commissioner and the Deputy Mayor require assurance on from HMICFRS:

a. Initial death categorisation and investigation procedures:

  • Effectiveness of the initial investigation to demonstrate that a death is treated as suspicious until it is confirmed, with evidence, that it is not.
    • To include ensuring whether ‘hate’[1] is being appropriately identified as a motivating factor and, if so, that appropriate external groups are engaged with (e.g. independent advisory groups and staff networks)
    • To include ensuring whether incidents are being appropriately identified as ‘linked’

b. Family Liaison processes in relation to death investigation;

  • effectiveness and sensitivity of the engagement with families, friends and those who knew the victim well, including feedback from independent sources, such as Coroners’ offices

c. Inclusion, Diversity and Equalities considerations when investigating death;

  • how protected characteristics may influence the investigative approach
  • effectiveness of supervisors, both within the investigative structure and the wider leadership, to consider inclusion, diversity and equalities impact
  • effectiveness of the engagement with communities and how subject matter expert advice, both within the Met and the community (recognising any intersectionality) is sought.

d. Leadership and accountability of death investigation;

  • effectiveness of the leadership and supervision of the investigation, including the record keeping and case management
  • effectiveness of the interaction between BCU officers and specialist homicide investigative teams, including the matter of primacy and support provided if the death remains locally investigated.

e. Learning lessons from ongoing investigations.

  • effectiveness of processes to ensure that learning is gathered from death investigations, promulgated and acted on within the MPS, to inform future investigations
    • to include appropriate use made of independent review mechanisms as the investigation progresses e.g. Specialist Crime Review Group.


  • The inspection will follow the HMICFRS standard approach of:
    • interviews/focus groups with officers, staff and stakeholders;
    • document review including strategies, policies, guidance, minutes of meetings, etc (recognising any specific comments made following the Coroner’s thorough review); and
    • review of data.
  • The approach will include reviewing previous cases of death investigations.
  • As is standard practice, should HMICFRS identify any areas of concern outside of the scope of this inspection, these will be highlighted to the Commissioner.

Stakeholder engagement

  • Stakeholders have been consulted on the terms of reference and will be engaged during the inspection as required.
  • The final report will be shared with the Mayor’s Office for Policing and Crime and subsequently published.


  • The inspection work will start in May 2022 and will take approximately six months.

[1] Hate motivation: Hate crimes and incidents are taken to mean any crime or incident where the perpetrator’s hostility or prejudice against an identifiable group of people is a factor in determining who is victimised. This is a broad and inclusive definition. A victim does not have to be a member of the group. In fact, anyone who is perceived to be or associated with an identifiable group of people, could be a victim of a hate crime or non-crime hate incident. (Definition from College of Policing Authorised Professional Practice Major investigation and public protection)

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Terms of reference: HMICFRS inspection following the East London Inquests touching the deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor