February 28, 2024

Lee Bowman: Prevention of future deaths report

Other related deaths

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Date of report: 08/11/2023

Ref: 2024-0109

Deceased name: Lee Bowman

Coroner name: Abigail Combes

Coroner Area: South Yorkshire East

Category: Other related deaths

This report is being sent to: College of Policing

	REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: [REDACTED], Chief Executive Officer, College of Policing
	CORONER l am Abigail Combes, Assistant coroner, for the coroner area of South Yorkshire (East District)
2	CORONER’S LEGAL POWERS 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.
3	INVESTIGATION and INQUEST On 12th January 2022 I commenced an investigation into the death of Lee Bowman born on 10th January 1977. The investigation concluded at the end of the inquest which commenced on the 8th November 2023. The conclusion of the inquest was: An open conclusion In box three it was recorded On 2 November 2021 Lee Bowman was reported missing to police by his family. The last sighting of him was on 31 October 2021. His body was found at 62 Green Arbour Road, between two fence panels in the garden on 3 January 2022 The medical cause of death was: 1a: Unascertained
4	CIRCUMSTANCES OF THE DEATH Lee Bowman was last seen by his family on 29 October 2021 going to his girlfriend’s home address in South Yorkshire. His family did not hear from him after this and that was out of character for Lee who would ordinarily be in touch with his family hourly during the day. Lee did not possess his own phone and therefore family had to rely on Lee contacting them rather than being able to ring him themselves. Lee had a number of underlying health conditions including mental health conditions and history of self harm. He also had recently had a diagnosis of liver cirrhosis which was causing him concern. On top of that his father had recently been diagnosed with cancer and that had upset him. On 31 October 2021 Lee was reported as being seen in the vicinity of his girlfriend’s home address with injuries consistent with being assaulted. This is the last unquestioned sighting of Lee before his body is found. On 2 November 2021 Lee was reported missing to Nottinghamshire Police by his brother. His brother reports that they haven’t heard from him and that this was out of character for Lee. He also makes reference to mental health problems and that he has not taken it well that his father has been diagnosed with cancer. Nottinghamshire Police determined that this is not a true missing person enquiry at this stage as it is not clear that he is actually missing, and they asked South Yorkshire Police to make enquiries at th.e last known address that Lee was going too. The log that Nottinghamshire police hold is updated before the addition of information ·from South Yorkshire police confirming that they had attended at his girlfriends address and she said she had kicked him out two days previously. The matter then returned to Nottinghamshire Police who closed the incident down as a deliberately absent individual. On 4 November 2021 Lee’s father also reported Lee missing as they had still not heard from him. This commenced the missing person investigation from Nottinghamshire Police. There were a number of sightings reported of Lee when media appeals were issued. These were both in South Yorkshire and Nottinghamshire. These were not necessarily thoroughly checked for accurateness although they were followed up by officers in Nottinghamshire. These sightings gave false assurance that Lee was well and was not contacting family for unknown reasons. The sightings included a sighting by a police officer and this check was assessed as being particularly reliable however there was insufficient scrutiny applied to that veracity of that sighting. In any event, that sighting was in early November still leaving days unaccounted for. There was no referral to detectives from Nottinghamshire Police and instead the investigation was transferred to South Yorkshire Police on 28 November 2021. This was closed by South Yorkshire Police as a result of an incorrectly confirmed sighting by a PCSO of Lee. The case was reopened by South Yorkshire Police on 7 December 2021 following a call from Lee’s family confirmed that he had still not been seen. When the case was reopened on the 7 December 2021 and then reviewed on the 9 December with the grading being low risk. This was revisited on the 10 December and despite no particular change to the circumstances it was revised to be Medium risk. On 14 December 2021 the missing person report was regraded as high as it was apparent that the sightings were unconfirmed sightings. This resulted in detectives being asked to lead the investigation who undertook a number of enquiries including CCTV, door to door enquiries and financial and phone enquiries. It appears that it was not until 31 December 2021 that the police in South Yorkshire became aware of the jacket which Lee was wearing in the last known sighting, being found and that narrowing the search scene to near where Lee was ultimately found. Between Lee’s reported disappearance on 2 November 2021 right up until his body was found on 3 January 2022 there had been no activity in Lee’s bank account and no contact with his family despite his usual levels of contact with them. [REDACTED], gave evidence that there were four possible medical explanations for Lee’s death:- Liver disease Hyperthermia Drug or alcohol use Positional asphyxia However, he also explained that there was not enough pathological evidence to be persuaded by to give a preference and for that reason he had to return unascertained and rely upon the inquest to try and ascertain the circumstances. There was no evidence heard during the inquest that assists with the circumstances beyond Lee having been seen with injuries in the vicinity of where his body was found on 31 October 2021. [REDACTED], was clear that Lee had been where he was found for some time but could not be precise as to when he had died. The following findings were made during the inquest: – The decision making around the closure of the Log created when Lee was first reported missing on 2 November 2021 was lacking in clarity and has been largely based on presumption. The log appears to have been closed before the clarity has been received from South Yorkshire Police about whether or not Lee was at his partners address and seems to be based upon intelligence information held by the police rather than risk assessment of the current situation which Lee was in at the time that he went missing. That said, even if the log had remained open and a missing persons case been commenced it is apparent that a key factor for Nottinghamshire police’s risk assessment when Lee was reported again on 4 November was the fact that his money had gone into his account on 3 November but that it had not been touched. This would not have been the case on the 2 November and therefore it cannot be confirmed whether that would have made a difference to the searches that were conducted for Lee on that date. On the basis of [REDACTED], evidence, it cannot be said whether Lee was already dead on 2 November 2021. The checks conducted by South Yorkshire Police on 2 November 2021 lacked professional curiosity. When it was confirmed that Lee had been kicked out of the house and not seen since there was no sense that this might require any additional follow up or any further enquiries made of his then partner about whether he was ok when he left the address. Whilst this is unlikely to have made a difference to the overall outcome it was a missed opportunity to gather information and intelligence about Lee’s condition at the time he was a missing person. There was evidence of unconscious bias influencing the decision making and judgments of officer’s risk assessing. For example, there were assumptions that Lee led a chaotic lifestyle and therefore was not missing but choosing not to be found as he was drunk somewhere. This was never triangulated with the fact that he had not touched his bank account and even within the confines of his addiction, he ordinarily maintained contact with his family which he did not do here. Police also relied upon sightings from those who lead similarly ‘chaotic’ lives to demonstrate that Lee was well and just had not been located. Again, this was not weighed against the body of evidence from the family that he was unwell and was not in contact with them which was out of character. Once detectives took over the inquiry on the 14 December 2021 matters picked up in PACE and enquiries were undertaken with greater clarity and order however in reality nothing had substantially changed in Lee’s position in that time. What was discovered in December 2021 was that the sightings relied upon in fact could not be relied upon and had not been adequately scrutinised. Unfortunately, the evidence from the pathologist was such that it cannot be said when Lee died and therefore the point at which he could still have been found alive cannot be identified. The decisions in respect of the searches therefore cannot be said, even on the balance of probabilities, to have made a difference to the outcome for Lee.
5	CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: There were significant assumptions made about the whereabouts of Lee and the reasons for his failure to contact family. The assumptions were based on the facts of Lee’s addiction which on one view ought to have been identified as a vulnerability, on another view were wholly irrelevant in the context of his family confirming he was in daily contact until 31 October 2021. Insufficient weight was placed on the information provided by Lee’s family about his current state of mind and ordinary behaviours. Although there was a THRIVE assessment undertaken by the call handler on 2 November 2021 when the first missing person report was made, the burden of the weight fell on his PNC record and police intelligence information painting a picture which was not representative of the concerns of his family.
6	ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 4^th 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.
8	COPIES and PUBLICATION l have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Lee Bowman, Deputy Chief Constable of West Yorkshire Police as the National Police Chief Council Lead for Missing Persons, Home Office, Chief Constable of South Yorkshire and Chief Constable of Nottinghamshire Police. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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.
9	8th November 2023 Mrs A Combes, Assistant Coroner