Gracie Spinks: Prevention of future deaths report

Other related deaths

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Date of report: 27/11/2023

Ref: 2023-0479

Deceased name: Gracie Spinks

Coroner name: Matthew Kewley

Coroner Area: Derby and Derbyshire

Category: Other related deaths

This report is being sent to: Derbyshire Constabulary | Home Office

The Chief Constable of Derbyshire Constabulary
The Rt Hon James Cleverly MP, Secretary of State for the Home Department
I am Matthew Kewley, Assistant Coroner, for the coroner area of Derby and Derbyshire.
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 21 June 2021 I commenced an investigation into the death of Gracie Elizabeth Spinks (“Gracie”) who was 23 years old when she died on 18 June 2021. The investigation concluded on 16 November 2023 at the end of the inquest heard with a jury.

The jury concluded that Gracie was unlawfully killed by a former work colleague on 18 June 2021.
Gracie was born in 1997. In 2020 Gracie started working for a company in Chesterfield called Xbite. Whilst working at Xbite, Gracie met up on a number of occasions outside of work with a male colleague who was employed as a supervisor at Xbite. Gracie decided that she did not want to have any sort of relationship with the supervisor and made this clear to him in December 2020. The supervisor failed to accept Gracie’s decision and became obsessed and fixated with her. Gracie reported the supervisor’s behaviour to Xbite in January 2021 and he was subsequently dismissed from Xbite in February 2021.  

Gracie also reported the supervisor’s stalking behaviour to Derbyshire Constabulary in February 2021. A police investigation was carried out which resulted in no action being taken against the supervisor. The supervisor was given ‘words of advice’ by the investigating police officer.  

In May 2021 a member of the public found a rucksack containing multiple weapons on a public footpath near to the field where Gracie kept her horse. The member of the public was concerned about the contents of the rucksack and reported this to Derbyshire Constabulary. The attending police officers treated the rucksack as if were simply an item of found property and failed to carry out any form of investigation into the rucksack and its contents.

On 18 June 2021 Gracie was unlawfully killed by the supervisor who she had reported to Derbyshire Constabulary in February 2021. Gracie died as a result of a stab wound to the neck. It was established after Gracie’s death that the rucksack found by the member of the public in May 2021 containing weapons belonged to the supervisor who killed Gracie.
At the inquest into Gracie’s death Derbyshire Constabulary accepted that there were multiple serious police failings in respect of the stalking investigation in February 2021 and the rucksack incident in May 2021. Those failings were recorded by the jury on the Record of Inquest but it could not be determined that those failings contributed to Gracie’s death on 18 June 2021.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
Derbyshire Constabulary:
Stalking – during the inquest I heard evidence from the police officers who were involved in investigating Gracie’s stalking complaint in February 2021. Derbyshire Constabulary accepted that there were serious failings in how Gracie’s complaint was investigated by these officers. I do recognise that Derbyshire Constabulary has taken some steps following Gracie’s death to improve knowledge around stalking. However, as the Detective Chief Superintendent who gave evidence for the Constabulary accepted, more needs to be done to improve knowledge and understanding around how officers should investigate complaints of stalking. Consideration may be given to:
Reviewing the current force guidance/training on stalking and considering whether further guidance/training is required in light of the issues identified during the inquest (including consideration of whether there ought to be a force policy on stalking);
Re-enforcing understanding of the existing training/guidance on stalking including consideration of further training sessions/briefings to emphasise the key issues around investigating complaints of stalking, particularly in relation to the need to investigate the stalking complaint fully in order to identify potential patterns in the suspect’s alleged behaviour;
Ensuring officers are aware of the available resources on stalking and, crucially, the importance of actually consulting the available resources on stalking when police officers are investigating stalking cases to ensure that investigations are conducted in line with expected standards.
Risk assessments – during the inquest I saw a number of good quality risk assessments completed by police call handlers/officers who were involved in the very early stages of Gracie’s stalking complaint in February 2021 and also the rucksack incident in May 2021. However, it became apparent during the inquest that the police officers who were subsequently allocated to deal with the stalking complaint and the rucksack incident failed to record any form of risk assessment or fully assess the potential risks. As was recognised by the Detective Chief Superintendent who gave evidence for the Constabulary at the inquest, the crime report for the stalking investigation in February 2021 lacked any sort of risk assessment or even a recognition of potential risks. I heard evidence from the police officers involved in the stalking investigation and the rucksack incident and I am concerned that there may be an ongoing lack of understanding about the importance of completing comprehensive risk assessments which include the initial identification of risk and also, importantly, a regular re-assessment of risk as the investigation progresses. I consider that further steps should be considered in order to improve understanding and appreciation of the importance of completing comprehensive risk assessments.
Independent Office for Police Conduct (“IOPC”) – the IOPC carried out an investigation into the conduct of the five officers involved in the stalking investigation and the rucksack incident. The IOPC made a number of recommendations to Derbyshire Constabulary which included:
‘2. To consider how stalking offence locations are recorded on Niche. There does not appear to be any guidance to suggest that all of the locations of the stalking offending are tagged to the incident individually. In this instance it may not have made any difference as the officers who received the bag did not do a search of police systems for the area. However, in future that may well be done, and it could make the difference between linking risk and suspects.’
I heard evidence about this issue from the Detective Chief Superintendent on behalf of the Constabulary and I am concerned that more needs to be done to engage with this specific recommendation from the IOPC. The inquest heard that specific geographical locations can be particularly important in stalking investigations (i.e the horse field in Gracie’s case). As such, it seems to me that the IOPC recommendation is an important one which could assist in future cases with linking suspects and particular locations relevant to the stalking investigation.
Contemporaneous note taking/record keeping – during the inquest I heard that police officers failed to make any contemporaneous notes of important steps in the police investigation including, for example, conversations with an informant/member of the public, words of advice given to a suspect, a telephone call to a potential witness and also an internal police discussion between a police constable and police sergeant discussing the closure of an investigation. The written crime reports reviewed during the inquest also lacked sufficient detail around these important conversations/investigative steps – in other words, the crime reports did not compensate for the lack of contemporaneous notes.
I am concerned that a lack of contemporaneous notes/insufficient detail within a crime report may impact on the ability to make properly informed risk assessments which rely on the existence of a good written record of important conversations/steps taken during an investigation. This may become an issue where, for example, an investigation is re-allocated to another police officer who has had no prior involvement in the investigation such that the newly allocated police officer will be reliant upon the quality of the original police officer’s records/notes.

Potential weapons/dangerous items found in the community – during the inquest I heard that police officers attended to a report of a rucksack containing weapons found by a member of the public in May 2021. Despite the rucksack containing weapons, it was treated by the attending police officers as if it were an item of found property. Derbyshire Constabulary accepted that there were serious failings in how the officers dealt with this incident. During the inquest, I heard that there has been another recent incident around 11 August 2023 in which a child found a knife concealed in bushes in a local park. The knife was concealed in a sock and the child’s parent was concerned that the knife had been concealed so that it could be used at a later date. Despite the obvious potential danger, the police call handler advised the member of the public to ‘destroy’ the knife and advised that police would not be attending. Whilst I recognise that further steps have been taken very recently in response to this latest incident, I am concerned that there appears to be an ongoing issue within Derbyshire Constabulary around the ability of some police officers/staff to deal effectively with reports of potential dangerous weapons found in the community.
The Rt Hon James Cleverley MP, Secretary of State for the Home Department:
Independent Stalking Advocates – during the inquest I heard evidence about the benefits that stalking advocates can provide to those who are victims of stalking. Whilst I was reassured to hear that Derbyshire now benefits from stalking advocates, I heard evidence that many other areas around the UK do not have stalking advocates. This essentially creates a postcode lottery for victims who report stalking to the police. I am concerned about the lack of consistency and availability of stalking advocates to victims of stalking across the UK.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 January 2024. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Gracie’s family
Derbyshire Constabulary

I have also sent it to the following individuals who may find it useful or of interest:
[REDACTED] , National Police Chief Council Lead for Stalking and Harassment
[REDACTED], Police and Crime Commissioner for Derbyshire
[REDACTED], MP for Chesterfield

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9Matthew Kewley
Assistant Coroner for Derby and Derbyshire 27 November 2023