Complaint Investigation name Gaia Pope-Sutherland

Complaint

Investigation name

Investigation subtitle

Gaia Pope-Sutherland

Investigation into a missing person enquiry by

Dorset Police

Independent investigation report

> Investigation information

Investigation name: Gaia Pope-Sutherland

IOPC reference: 2018/100098

Investigation type: Complaint subject to special

requirements

IOPC office: Cardiff

Lead investigator: Martyn Coombe

Case supervisor: Sarah Patten

Director General delegate

(Decision maker):

Mel Palmer

Status of report: Final

Date finalised: 11 November 2019

> Contents

Introduction ......................................................................................................... 4

The investigation ................................................................................................. 9

Subjects of the investigation ............................................................................. 10

Policies, procedures and legislation considered ............................................... 11

Summary and analysis of the evidence ............................................................. 21

The first calls to police ....................................................................................... 22

The initial risk assessment ................................................................................ 31

Searches by the National Police Air Service (NPAS) ........................................ 39

Searches on the ground during the first twenty-four hours ................................ 47

Searches on the ground after the first twenty-four hours .................................. 77

Liaison between the police and civilian volunteers ............................................ 98

The search for Gaia’s phone ........................................................................... 107

The arrests and subsequent murder investigation .......................................... 110

The discovery of Gaia’s clothing ..................................................................... 118

Liaison between the police and the family ....................................................... 128

Learning identified during the IOPC investigation ........................................... 145

Next steps ....................................................................................................... 148

Summary for publication ................................................................................. 148

Appendix 1: The role of the IOPC ................................................................... 151

Appendix 3: Glossary ...................................................................................... 162

> Introduction

> The purpose of this report

1. I was appointed by the IOPC to carry out an independent investigation into

the Dorset Police response to reports Miss Gaia Pope-Sutherland (referred to

as Gaia in this report) was missing.

2. At approximately 3.40pm

on 7 November 2017, Gaia was recorded on CCTV

running south along Morrison Road in Swanage.

3. At 3.42pm, Gaia’s aunt called Dorset Police for assistance. She explained

that Gaia was due to see her GP regarding a referral to the Mental Health

Team, but had run out of the house in search of a childhood friend (referred

to in this report as Male A).

4. A relative of Male A (Female A), later told officers that Gaia arrived at her

house between 3.30pm and 4pm. Female A stated that Gaia was behaving

irrationally and eventually left, saying she was going to see her friend, Female

B. When spoken to, Female B and her family stated that they had not seen

Gaia that day.

5. At approximately 3.59pm

, Gaia was recorded on CCTV on Priests Road in

Swanage, walking west towards the outskirts of town.

6. At 4.52pm, Gaia’s mother called Surrey Police

to report Gaia missing. During

the call, she stated that Gaia suffered from epilepsy and mental health issues,

and had been sectioned in the past.

7. At 4.57pm, Surrey Police emailed a missing person report to Dorset Police.

8. At 6.15pm, Gaia’s aunt called Dorset Police again to report Gaia missing.

9. At 6.18pm, Dorset Police completed a missing person report based on

information provided by Gaia’s aunt. The report was initially assessed as

medium risk, but was upgraded to high risk at 1.24am on 8 November 2017.

10. In the days that followed, Dorset Police explored a number of different lines of

enquiry in the search for Gaia. Devon and Cornwall Police, Dorset Search

and Rescue (DorSAR), Hampshire and Berkshire Search and Rescue, HM

The footage was time-stamped 3.39.57pm, but was later found to be 30 seconds slow, so the

correct time would have been 3.40.27pm.

The footage was time stamped 4.54pm, but was later found to be 55 minutes fast, so the correct

time would have been 3.59pm. This footage was discovered after Gaia was found deceased.

Gaia’s mother lives in Dorset, but was in the London area when Gaia went missing, so her call was

put through to Surrey Police.

Coastguard, Dorset and Wiltshire Fire and Rescue Service (DWRFS) and

members of the public also assisted with the search.

11. On 13 November 2017, officers arrested Male A and Female A on suspicion

of murder. They were released under investigation the following day.

12. On the morning of 16 November 2017, members of the public found Gaia’s

clothing in a field near the cliffs south of Swanage. Later that day, officers

arrested a relative of Male A and Female A (Male B), on suspicion of murder.

He was released under investigation the following day.

13. On 18 November 2017, Gaia was found deceased in dense undergrowth

approximately 300 metres from her discarded clothing, near a coastal path

known as the Zig Zag. She had no injuries to suggest third-party involvement,

and a post-mortem examination concluded that she had died from

hypothermia.

14. On 20 November 2017, Dorset Police confirmed that they would not be taking

any further action against Female A, Male A or Male B.

15. This matter came to the attention of the IOPC on 23 February 2018 as a

Death or Serious Injury (DSI)

referral, and the IOPC decided to carry out an

independent investigation.

16. On 2 May 2018, Gaia’s family complained to the IOPC that Dorset Police had

failed to carry out an appropriately prompt and thorough search. The IOPC

investigation was subsequently reclassified as a complaint investigation.

17. Between November 2018 and October 2019, IOPC investigators obtained

accounts from over a hundred witnesses. One of those interviewed was

Constable A, who was an Acting Sergeant when Gaia went missing. Certain

aspects of Constable A’s account were found to be inconsistent with the other

evidence, and on that basis, the IOPC investigation was declared subject to

special requirements

on 6 August 2019.

18. In an IOPC investigation, the powers and obligations of the Director General

(DG) are usually delegated to a senior member of IOPC staff, henceforth

referred to as the decision maker. The decision maker for this investigation is

Operations Manager Mel Palmer.

19. In this report, I will provide an accurate summary of the evidence, and attach

or refer to any relevant documents. I will also provide sufficient information to

enable the decision maker to determine:

Paragraph 12 of the Police Reform Act 2002 defines a DSI matter as any incident in which a

member of the public has died or sustained a serious injury in police custody, or following police

contact, and where there is an indication that the police contact may have caused or contributed to

the death or serious injury. Schedule 3, paragraph 14C of the Police Reform Act 2002 states that

police forces must refer all DSI matters to the IOPC.

Paragraph 19(B), Schedule 3 of the Police Reform Act 2002 states that an investigation will be

declared subject to special requirements if there is an indication that a person serving with the police

may have committed a criminal offence, or behaved in a manner that would justify disciplinary

proceedings.

 whether the family’s complaints are upheld, where appropriate (i.e.

where this would not intrude on any associated criminal or misconduct

proceedings);

 whether any person serving with the police has a case to answer for

misconduct or gross misconduct, or no case to answer, or whether any

such person’s performance was unsatisfactory;

 whether disciplinary proceedings should be brought against any person

to whose conduct the investigation related, and the form of any such

proceedings;

 whether to refer any matter to the Crown Prosecution Service (CPS)

;

 whether to make a recommendation to any organisation about any

lessons that may need to be learned.

On receipt of this report, the decision maker will record her opinion on the20.

above matters.

The IOPC will then send a copy of this report and the decision maker’s21.

opinion to Dorset Police, who must advise the decision maker what action, if

any, they will take in response to the investigation findings. If the decision

maker does not agree, she may make recommendations and ultimately

directions for further actions or determinations.

> Background information about Gaia

22.

23.

24.

25.

26.

Paragraph 23(2)(b) and (c) of the Police Reform Act 2002 set out the criteria for referral to the CPS.

The IOPC has also investigated how Dorset Police dealt with the rape allegation. The findings from

that investigation are outlined in a separate report.

charges. He was

sentenced to two years in prison.

Gaia normally lived with her mother and two sisters in Langton Matravers.

However, in the weeks before she went missing, she stayed with her aunt in

Gaia Pope-Sutherland was born on 22 July 1998. She suffered from severe

epilepsy, exacerbated by stress, for which she was prescribed medication.

She could have up to twenty or thirty seizures a day, and would often

experience periods of confusion and disorientation following major seizures.

In December 2015, Gaia’s sister contacted Dorset Police to report that Gaia

had been raped approximately twelve months ago, at the age of sixteen. At

that time, the suspect was already under investigation by Dorset Police for

offences.

In June 2016, Dorset Police decided to take no further action in relation to

Gaia’s case

on the grounds that there was insufficient evidence to support a

prosecution.

Gaia’s alleged rapist pleaded guilty to three unrelated

Swanage, and occasionally with her uncle in Bournemouth. She had been

staying with her uncle in the days before she went missing.

27. On 7 November 2017, Gaia was due to meet with the police to discuss an

incident five days before in which a man had sent her sexually explicit images

via Facebook messenger.

28. Gaia’s aunt stated that Gaia began acting strangely at around 3.30pm that

day, and left the house in search of Male A. She stated that she tried to follow

Gaia in her car, but lost sight of her on Morrison Road.

29. Gaia’s family reported that her mental health had deteriorated significantly in

the days leading up to her disappearance. They believe this deterioration was

caused by her anxiety over her alleged rapist’s imminent release from prison,

and was further exacerbated by the incident involving the explicit images.

30. Gaia’s cousin read out a statement on behalf of the family at the opening of

the inquest. She described Gaia as “loving, joyful and brave… a bright and

powerful young woman who wanted to devote her life to others.”

> Complaints made by Gaia’s family

31. Gaia’s family complained that Dorset Police initially failed to recognise that

Gaia was high risk, even though they knew she was vulnerable. They

expressed their belief that Gaia might have been found alive if the police had

treated her as high risk from the outset. They stated that, days into the

search, officers still seemed unaware of the seriousness of her epilepsy.

32. They alleged that the initial risk assessment was influenced by assumptions

about Gaia, stemming from the rape investigation.

33. They further alleged that the police failed to act on critical information

provided by family members, and failed to carry out diligent and thorough

searches of the areas identified. In particular, they stated that Gaia’s mother

and sister told the police at a very early stage that Gaia would be likely to go

to Priests Way and Dancing Ledge. They stated that the police assured them

this area had been searched thoroughly in the first 48-72 hours, using search

dogs and thermal imaging cameras, and that one officer told Gaia’s cousin, “If

Gaia had been there, we would have found her.”

34. The family expressed their distress and concern over how long it took to find

Gaia’s clothes and her body. They stated that Gaia’s clothes were found on a

direct route from where she was last seen, and should have been visible from

the upper coastal path.

35. They further stated that the police initially refused to allow Gaia’s aunt to view

and positively identify the clothes as belonging to Gaia.

36. They alleged that the police failed to organise the searches so that they were

effective, and failed to utilise resources properly. In particular, they alleged

that the police did not liaise properly with the teams of civilians who

volunteered to help. They stated that this was an exceptional and critical

resource which, had it been utilised properly, would have contributed

significantly to the search effort.

37. They stated that a Facebook page was set up on 8 November 2017, with a

log of locations that had been searched by civilian volunteers. They stated

that the police refused to look at the Facebook page, and that one officer told

Gaia’s cousin they were “not allowed to use Facebook.”

38. They stated that the police did not contact the civilian volunteers directly until

11 November 2017, and did not give them any clear or concrete instructions

on how best to search. They stated that the police failed throughout to

communicate properly with the civilian search teams, resulting in a chaotic

and disorganised approach to the search.

39. They stated that the police forbade the civilian volunteers from searching rural

areas due to safety concerns, but assured the family these areas had already

been thoroughly searched. The family stated that, given where Gaia was

found, they had no confidence that these areas had been searched properly.

40.

They

alleged that, when questioning Gaia’s sister about Gaia’s whereabouts, an

officer asked her whether she knew “how much money [the search] was

costing”.

41. The family complained that their Family Liaison Officer (FLO) (referred to in

this report as FLO A) did not assist with arranging mental health support for

them, and was often unreachable by phone. They further alleged that he

inappropriately attended Gaia’s aunt’s home on the evening of 17 November

2017, questioned her about footage that had been released to the media,

encouraged her to write and sign a statement about her movements on the

day Gaia went missing, and discouraged her from obtaining legal advice.

42. The family queried whether the arrests on 13 and 16 November 2017 were

lawful. They stated that they were told the police arrested Male A and Female

A because their stories “did not add up”; which turned out to be because the

clock on a CCTV camera was faulty. They stated that the police told them

that, due to a recent change in policy, arresting someone on suspicion of

murder was the only way they could search their address and interview them

over a sufficient period. The family stated that this explanation was confusing,

and suggested that the police did not have reasonable grounds to suspect an

offence. The family expressed the view that the arrests discouraged the

civilian volunteers, and may have had an impact on the police search,

specifically on the deployment of helicopters.

43. Finally, the family alleged that Dorset Police failed to provide accurate

information to them, particularly in relation to Gaia’s final resting place, which

caused them significant distress.

> Appendices to this report

44. Appendix 1 outlines the role of the IOPC.

45.

46. Appendix 3 features a glossary of police terms and acronyms that may not be

familiar to the reader.

47.

> The investigation

> Terms of reference

48. Operations Manager Mel Palmer approved the terms of reference for this

investigation on 15 June 2018.

49. On 30 August 2019, the terms of reference were amended to reflect the fact

that the investigation had become a conduct investigation.

50. The terms of reference are as follows:

1. To investigate the Dorset Police response to the missing person report

made in respect of Miss Gaia Pope-Sutherland on 7 November 2017,

specifically:

a) To address the complaints made by Gaia’s family;

b) To examine the actions and decisions of the officers dealing with

the missing person report, up to the discovery of Gaia’s body;

c) To consider whether the missing person report was appropriately

risk assessed, reviewed and resourced; and

d) To consider whether police action was in accordance with

applicable legislation and local and national guidance, policies and

procedures regarding missing persons.

2. To assist in fulfilling the state’s investigative obligation arising under the

European Convention on Human Rights (ECHR) by ensuring as far as

possible that the investigation is independent, effective, open and

prompt, and that the full facts are brought to light and any lessons are

learned.

3. To identify whether any subject of the investigation may have committed

a criminal offence and, if appropriate, make early contact with the

Director of Public Prosecutions (DPP). On receipt of the final report, the

decision maker shall determine whether the report should be sent to the

DPP.

4. To enable an assessment as to whether any subject of the investigation

has a case to answer for misconduct or gross misconduct or no case to

answer.

5. To consider and report on whether there may be organisational learning,

including:

 whether any change in policy or practice would help to prevent a

recurrence of the event, incident or conduct investigated;

 whether the incident highlights any good practice that should be

shared.

> Subjects of the investigation

51. Any police officer, police staff member or relevant contractor whose conduct

is under investigation will be classed as a subject of the investigation.

52. All subjects must be served with a notice of investigation informing them of

the allegations against them, and stating whether the allegations would

amount to misconduct or gross misconduct if proven.

53. Constable A was served with a notice of investigation on 14 August 2019,

worded as follows:

“On the afternoon of 7 November 2017, you were the acting sergeant at

Wareham police station with responsibility for policing of the Wareham and

Swanage areas. During the course of the afternoon you became aware that

Miss Pope-Sutherland was missing, and that [Constable B] was making

enquires in an attempt to locate her.

You have provided two witness statements at the request of the IOPC Lead

Investigator, in which you have detailed your actions on the afternoon and

evening of 7 November 2017.

Following a review of those statements, other documentation and statements

from other officers obtained, it is alleged that:

1. You failed to satisfactorily handover the missing person investigation

into Ms Pope Sutherland to ensure appropriate progress, in that:

2. You failed to inform the covering night shift sergeants in Poole, who

were responsible for policing Wareham and Swanage overnight 7-8

November 2017, that Miss Pope-Sutherland was missing. Neither did

you inform any other supervisory officer, who could have taken the

investigation forward.

3. You failed to appropriately task the Wareham night shift officers with

carrying out any enquires in an attempt to locate Miss Pope-Sutherland.

4. You failed to document and record any enquires you instructed to be

carried out, if indeed you did request any such actions.

If proven, this may amount to a breach of the standards of professional

behaviour in relation to duties and responsibilities.”

54. These allegations were assessed as amounting to misconduct if proven or

admitted. IOPC investigators interviewed Constable A under misconduct

caution on 22 August 2019.

> Policies, procedures and legislation

considered

55. During the investigation, I have examined relevant national and local policies

and legislation, as set out below. This information will enable the decision

maker and the appropriate authority to consider whether the officers and staff

named in this report complied with the applicable guidance and legislation,

and whether the existing policies were sufficient in the circumstances.

> The National Decision Model (NDM)

56. The College of Policing is the professional body for people who work in

policing. The College of Policing Authorised Professional Practice (APP) is a

comprehensive body of online guidance on policing. Police officers and staff

are expected to consider the APP when discharging their responsibilities.

57. The APP states that police officers should adopt the following process when

making a decision:

 Consider what information and intelligence is available and/or required;

 Assess the threat and risk, and develop a working strategy;

 Consider what powers and policies apply;

 Consider what options are available to resolve the situation with the

least risk of harm, and develop a contingency plan;

 Consider whether the decision is consistent with the police Code of

Ethics

; and

 Take action, review the outcome, and repeat the above stages if

necessary.

58. This process is known as the National Decision Model (NDM).

> The College of Policing Authorised Professional Practice

(APP) on Missing Persons

The Code of Ethics was produced by the College of Policing as a code of practice under section 39A

of the Police Act 1996 (as amended by section 124 of the Anti-Social Behaviour, Crime and Policing

Act 2014). It sets and defines the standards of behaviour for everyone who works in policing.

59. The College of Policing APP on Missing Persons

states that anyone whose

whereabouts cannot be established will be considered missing until they are

located, and their well-being or otherwise confirmed.

60. The APP states that a missing person should be graded as medium risk if the

risk of harm to the subject or public is deemed likely but not serious. It states

that this category requires an active and measured response by the police

and other agencies, in order to trace the missing person and support their

family.

61. The APP states that a missing person should be graded as high risk if the risk

of serious harm to the subject or public is deemed very likely. Risk of serious

harm is defined as “A risk which is life threatening and/or traumatic, and from

which recovery, whether physical or psychological, can be expected to be

difficult or impossible.”

62. The APP states that a high risk case requires the immediate deployment of

police resources, although action may be delayed in exceptional

circumstances, such as when searching water or forested areas in darkness.

63. The APP states that, in high risk cases, a member of the senior management

team must be involved in setting initial lines of enquiry and approving staffing

levels. It further states that an Investigating Officer (IO), a Police Search

Adviser (PolSA), and possibly a Senior Investigating Officer (SIO) should be

appointed, family support should be put in place where appropriate, and the

NCA Missing Persons Bureau (MPB) should be notified “without undue

delay”. A missing person process chart outlines the appropriate police

response to the different risk categories .

64. The APP states that certain minimum actions should be undertaken in all

cases, including completing a risk assessment, and creating and recording a

plan of immediate actions.

65. It states that police forces must submit case details to the MPB in all cases

where the person is still missing after 72 hours. If a case is of particular

concern (for example, if a serious crime is suspected or if there is significant

public or media interest), the MPB should be notified immediately.

66. The APP states that, in such cases, police forces should also consider

contacting the National Crime Agency (NCA) Specialist Operations Centre

(SOC), for support and expert advice.

67. The APP lists charities that can provide families with advice and support,

including Missing People, the Lucie Blackman Trust, the Samaritans and

Mind.

68. The APP on Risk Assessment

states that risk assessments should be

based on current risk levels, and should not be driven by previous

assumptions or experiences.

College of Policing APP, Missing Persons, www.app.college.police.uk/app-content/major-

investigation-and-public-protection/missing-persons/, accessed on 2 April 2019.

College of Policing APP, Risk Assessment, www.app.college.police.uk/app-content/major-

investigation-and-public-protection/missing-persons/risk-assessment/, accessed on 3 April 2019.

69. The APP on Missing Person Investigations

states that the first officer

deployed to a report of a missing person should (among other things):

 Gather sufficient information about the missing person to enable an

effective and thorough investigation to be conducted;

 Consider taking a full statement from the person making the report

and/or the last person to see the missing person;

 Conduct initial searches of relevant premises, and record the extent

and nature of any searches;

 Obtain details of the individual’s mobile phone and, if they have the

phone with them, arrange for a TextSafe

message to be sent;

 Consider the need for specialist officers or resources; and

 Circulate details of the missing person to officers and relevant local

partners, such as hospitals, the ambulance service, taxi firms and bus

firms.

70. The APP states that first-line supervisors should (among other things):

 Review the risk assessment;

 Allocate sufficient resources to pursue an effective investigation, and

ensure that appropriate actions are taken to locate the missing person

without delay;

 Consider the need for an early media release where appropriate;

 Consider involving a detective, a PolSA, a senior management team

and child-specific services; and

 Consider the need for a multi-agency response.

71. The APP states that a supervisor should ensure the case is reviewed and the

risk reassessed at regular intervals, taking account of any new information.

The frequency of reviews will depend on the circumstances of the case.

72. The APP further states that the Investigating Officer should seek advice from

a PolSA as necessary when developing the search strategy.

College of Policing APP, Missing Person Investigations, www.app.college.police.uk/app-

content/major-investigation-and-public-protection/missing-persons/missing-person-investigations/,

accessed on 3 April 2019.

> The College of Policing APP Risk Principles

80. The Risk Principles

are a set of ten principles that are intended to support

decision makers and help them to make decisions about risks with greater

confidence. They are as follows:

1. The willingness to make decisions in conditions of uncertainty (i.e., risk

taking) is a core professional requirement of all members of the police

service.

2. Maintaining or achieving the safety, security and wellbeing of

individuals and communities is a primary consideration in risk decision

making.

3. Risk taking involves judgement and balance. Decision makers

are required to consider the value and likelihood of the possible

benefits of a particular decision against the seriousness and likelihood

of possible harm.

4. Harm can never be totally prevented. Risk decisions should, therefore,

be judged by the quality of the decision making, not by the outcome.

5. Making risk decisions, and reviewing others’ decisions, is difficult and

should take into account whether the decisions involved dilemmas or

emergencies, or were part of a sequence of decisions, or might

appropriately be taken by other agencies.

6. The standard expected and required of members of the police service

is that their risk decisions should be consistent with those that a body

of officers of similar rank, specialism or experience would have taken

in the same circumstances.

7. Whether to record a decision is a risk decision in itself, which should

be left to professional judgement. The decision on whether to make a

record, and on the extent of that record, should be made after

considering the likelihood of harm occurring and its seriousness.

8. To reduce risk aversion and improve decision making, policing must

learn from successes as well as failures. Good risk taking should be

identified, recognised and shared.

9. Since good risk taking depends on quality information, the police

service will work with partner agencies and others to share relevant

information about those who pose risk or those who are vulnerable to

the risk of harm.

10. Members of the police service who make decisions consistent with

these principles should receive the encouragement, approval and

support of their organisation.

> Dorset Police Missing Persons Policy and Procedure

College of Policing APP, Risk Principles, www.app.college.police.uk/app-content/risk-2/risk/,

accessed on 2 April 2019.

81. Section 3.1 of this policy (Definitions) states that anyone whose whereabouts

cannot be established will be considered missing until they are located, and

their well-being or otherwise is confirmed.

82. Section 3.2.1 (Categories of Missing Person) states that missing persons can

generally be categorised as follows:

1) Any child under the age of 18 whose whereabouts cannot be

established, or who is not at a place where they are expected;

2) A lost person who is temporarily disorientated and would wish to be

found;

3) A person who has voluntarily gone missing who has control over their

actions, and who has decided upon a course of action; or

4) A person under the influence of a third party who has gone missing

against their will, such as an abduction or murder victim.

83. Section 3.3 (Roles, Responsibilities and Assessment of Risk) states:

“All staff taking or reviewing a report of a missing person must start with the

viewpoint that it is a potential serious crime enquiry. All aspects of a missing

person enquiry must be dealt with expeditiously, particularly the interviewing

of witnesses and the searching of relevant addresses and place last seen or

last known place. It is essential that such enquiries focus on identifying

factors which may give cause for concern, e.g.:

 behaviour out of character

 no property/cash missing

 signs of violence

 previous history of domestic abuse

 indicators of honour based violence/forced marriage

 demeanour around time of disappearance

 recent Internet activity prior to disappearance

 Deteriorating mental health”

84. Section 3.3.1 (Role of Call Taker) states that when someone is reported

missing, the Call Taker will create a missing person report and alert the Force

Command Centre (FCC) supervisors, who will then conduct an initial risk

assessment in line with the NDM (see above) and determine whether the

person is high, medium or low risk.

85. Section 3.3.3 (Assessment of Risk) states that the Critical Incident Inspector

must conduct a further risk assessment within the next six hours.

86. Section 3.3.4 (The Risk Assessment Table) states that risk assessments

should be guided by the College of Policing risk principles, the NDM and the

Police Code of Ethics

87. The policy definitions and recommended responses for high and medium risk

missing persons mirror those in the College of Policing APP (see above).

88. Section 3.4.1 (Role of Force Incident Commander (FIC)) states:

The Code of Ethics sets and defines the standards of behaviour that are expected of everyone who

works in policing.

“The FIC, or delegated officer, based within the Force Command Centre, will

be responsible for detailing the initial pro-active enquiries in relation to all

missing person reports. The FIC will initially act as 'silver commander'. While

they will retain the initial accountability for progressing the enquiry it may be

appropriate for them to appoint 'bronze' leads for different elements of the

investigation such as a bronze search, bronze financial or bronze media. The

FIC must ensure that progress is being made with the established lines of

enquiry, maintaining regular contact with the Critical Incident Inspector.”

89. Section 3.4.2 (Role of Critical Incident Inspector (C2/D2)) states:

“The Critical Incident Inspector (C2/D2) covering the area the person is

reported missing from will play a pivotal role overseeing the investigation.

This will include taking responsibility for ensuring clear delegation of tasks,

investigative supervision, recording conventions, effective handover and

oversight at the Daily Management Meeting process. It must be clearly

recorded at all times who is controlling a missing person enquiry. The original

reviewing Critical Incident Inspector should, where possible, complete all

subsequent reviews to provide continuity and consistency.”

90. Section 3.5.1 (Homicide) states:

“One of the fundamental facts to be determined in a missing person

investigation is the reason why the subject has disappeared. In cases where

the circumstances are suspicious or are unexplained, use the maxim:-

IF IN DOUBT, THINK 'MURDER, CHILD AND ADULT SAFEGUARDING

AND INVESTIGATION'.

Failure to apply such thinking in past cases has led to the loss of valuable

investigative opportunities. This can ultimately result in failure to trace the

missing person or to establish sufficient evidence to convict a perpetrator.”

91. Section 3.6.2 (Use of Police Search Advisors (PolSAs)) states:

“PolSAs should be consulted in all high risk cases unless it is immediately

apparent that a search is not relevant at that point, e.g. the missing person

was seen to leave in a vehicle and it has not yet been located. PolSA should

be liaised with when the vehicle is located, as there is strong evidence that

the missing person will be located with the vehicle.

There has been considerable research into the behaviour of missing persons

that have produced some compelling statistics about the distance different

people are likely to have travelled and areas that they may gravitate towards.

Through this knowledge, training and experience PolSAs are able to provide

informed advice and where appropriate will plan and direct searches.

A PolSA may deem the incident suitable for the involvement of Dorset Search

and Rescue (DorSAR) who are a team of highly-trained volunteers who can

provide additional personnel and resources to a Police-led search and can

deploy to anywhere in the County within 2 hours.

Use will be made of dogs, helicopter and the marine section if deemed

necessary.

PolSAs have overall direction of the search and will compile the search plan.

They are responsible for directing all search assets and those persons

deployed.”

92. Section 3.6.3 (Lost Person Search Manager (LPSM)) states that the LPSM’s

duties and responsibilities include the following:

 Review the log/occurrence and produce a search strategy identifying

areas for IVCs and searches;

 Task police or volunteer search assets with specific search areas;

 Attend the scene and liaise directly with search assets on the ground

(although IVCs should not be delayed pending arrival of the LPSM);

 Record the results of these searches and keep the Critical Incident

Inspector updated;

 Provide a full hand on to a PolSA if needed, or to another LPSM if

approaching the end of a shift; and

 Review any outstanding high risk missing person within 24 hours, or at

the request of the Critical Incident Inspector/FIC/SIO.

93. Section 3.7 (Media) states:

“Involving the public can have positive results in locating missing people and

should be considered at an early stage. However, every case should be

judged on its own merits as there is a delicate balance to be struck in

appealing through various channels including the media for help in tracing

missing people. It should be considered that public appeals can have lasting

repercussions for victims and their families if they are prepared too hastily.”

98.

> The police power of arrest

99. Section 24(2) of the Police and Criminal Evidence Act (PACE) 1984 states

that a constable may arrest anyone whom he has reasonable grounds to

suspect of having committed an offence.

100. Section 24(4) states that the power of arrest is exercisable only if the

constable has reasonable grounds for believing that an arrest is necessary,

for any of the reasons listed under Section 24(5). These reasons include:

 To allow the prompt and effective investigation of the offence or of the

conduct of the person in question;

 To prevent the person in question causing physical injury to himself or

any other person;

 To prevent the person in question causing loss or damage to property;

 To prevent any prosecution for the offence from being hindered by the

disappearance of the person in question.

> HM Coastguard search procedures

101. HM Coastguard guidance on Land Search Planning states:

“Hasty Search

A hasty search is a swift, non detailed pass through an area or segment. The

searchers will be looking for a fairly obvious target or clues rather than

detailed investigation. This is a balance between early target detection and

life saving with lower POD

against higher a [sic] POD associated with a

more detailed search which will clearly take more time to plan and execute.

It is the usual initial response search type and is an acceptance of a

decreased POD against early detection and could equate to a search of the

'spokes' of the bike wheel.

Purposeful Wandering

This involves a closer examination of all the most likely areas and spots,

looking for the target and clues.

More thorough than a hasty search, it can still cover a relatively large area

and allows searchers to 'wander' within their search pattern and investigate

likely spots. The search is normally conducted in a line abreast format. The

maintenance of search discipline is important, with particular attention being

paid to spatial awareness between searchers i.e. how far is it estimated that a

searcher could actually see the target.”

> Family Liaison Officer (FLO) Guidance

102. This national guidance document was produced

by the National Policing

Improvement Agency (NPIA)

in 2008, on behalf of the Association of Chief

Police Officers (ACPO)

103. It states that an FLO’s role is to manage interaction with the family in an

investigation, and to liaise with the Senior Investigating Officer (SIO) to

ensure that families are treated appropriately, professionally and with respect

for their needs. However, as family members often hold vital information

about a victim’s lifestyle and associates, an FLO is also responsible for

gathering material and information that may assist the investigation.

104. The guidance states that FLOs will routinely take identification and

antecedent statements, but should only be tasked to conduct an interview

with a family member who is a significant witness after careful consideration

of the following:

 Whether the FLO has the skills to conduct such an interview;

 The extent to which the FLO’s position with the family is likely to be

compromised by the need to challenge the witness’s account;

 Whether the FLO’s knowledge of the case might inadvertently

contaminate the interview process; and

 Whether it is reasonable and realistic to expect the FLO to remain

sufficiently objective in view of the particular circumstances of the case.

105. The guidance states that, to establish trust, unrealistic promises should not

be made to the family, and it is vital that any commitments or assurances are

Probability of Detection.

The NPIA was dissolved in October 2013 and replaced by the College of Policing and the National

Crime Agency.

ACPO was replaced by the National Police Chiefs’ Council (NPCC) in 2015.

met. If a commitment cannot be honoured, this must be documented and a

timely explanation provided.

106. The guidance states that the family may require support and assistance with

a variety of issues, such as trauma arising from bereavement, funeral

arrangements, financial or legal advice, health or social services. The

guidance states that the nature of support required will vary considerably,

depending on the family’s individual needs, and as such, the family should be

fully involved in the decision-making process.

107. Appendices 6 and 7 to the guidance list various support organisations, most

of which are not necessarily relevant to a missing person enquiry. Appendix 6

states:

“If families are reluctant or unwilling to accept offers of help from [these]

organisations… FLOs should be proactive in seeking out and establishing

alternative support for families. There are other statutory and voluntary

organisations, community interest and religious groups that will be able to

offer practical support, help and, in some cases, counselling services. FLOs

should share this information with the families and assist the family to make

contact with such organisations if they so desire.”

> Summary and analysis of the evidence

> Introduction and overview

108. Gaia was reported missing on 7 November 2017. At that time, Dorset Police

had 63 live missing person cases, 11 of which were reported that same day.

Of the 11 reported that day, four were assessed as high risk, and five as

medium risk.

109. Dorset Police received a further 18 missing person reports between 6.15pm

on 7 November 2017 and midnight on 9 November 2017. Eight of those were

assessed as high risk, and three as medium risk.

110. In the ten days that followed, Dorset Police received a further 137 missing

person reports. Of these, 41 were assessed as high risk and 61 as medium

risk.

111. Dorset Police, DorSAR, DWRFS and HM Coastguard covered 2.5 square

kilometres (km

) of ground on foot during the search for Gaia, and National

Police Air Service (NPAS) and drone searches covered a further 40km

open ground. HM Coastguard searched 15km of coastline, and specialist dive

teams searched ten bodies of water. The search also covered 4.5km of

railway lines, and 25km of tracks and footpaths. It was estimated that over

1000 individual officer hours were spent searching for Gaia.

112. In addition to physical searches, Dorset Police pursued a number of other

lines of enquiry, including media appeals, hospital checks, house-to-house

enquiries, vehicle stop checks, enquiries with people known to Gaia and

people she might have encountered after going missing, online research,

financial checks, premises searches, and analysis of mobile phone data.

Dorset Police also investigated numerous reported sightings.

113. This investigation has not identified any evidence to suggest that a more

concentrated approach to these additional lines of enquiry might have

resulted in Gaia being found alive. Nor did our investigation identify any

notable individual or organisational failings in these areas. Accordingly, this

report will focus on certain key aspects of the search, including the initial

police risk assessment, the action taken during the first twenty-four hours, the

searches of the area where Gaia was eventually found, the arrests on 13 and

16 November 2017, and whether these arrests had any impact on the search

for Gaia.

114. The following summary does not reflect all of the material that was gathered

during this investigation; nor does it reflect the full magnitude and scope of

the search for Gaia.

115. On receipt of this report, the decision maker will record her opinion on

whether the family’s complaints are upheld, where appropriate, and on

whether Constable A has a case to answer for misconduct, and on whether

there is any evidence of unsatisfactory performance by any person serving

with the police.

116. The threshold test for a finding of case to answer is whether a reasonable

tribunal, properly directed, could reach a finding of misconduct or gross

misconduct on the balance of probabilities. I will not reach any determinative

findings in relation to misconduct or performance in this report.

> The first calls to police

> Contemporaneous evidence

117. At 4.13pm on 2 November 2017, Gaia called 101 to report that a man had

sent her sexually explicit images after she accepted a Facebook friend

request from him. A log was created in respect of her call, reference 345, and

arrangements were made to speak to her on 7 November 2017

118. At 12.10pm on 7 November 2017, Gaia’s aunt called Dorset Police to make

arrangements to bring Gaia to the police station. The Call Handler was

unable to find the log from 2 November 2017, so created a new log with

reference number 160. During this call, Gaia could be heard in the

background in apparent distress.

They did not set a time. It was agreed that Gaia’s aunt would take Gaia to the police station at

some point in the afternoon; when Gaia became distressed, her aunt suggested waiting to see if she

was well enough to attend the police station after her 5pm GP appointment.

119. At 12.32pm, log 160 was updated to reflect that it was a duplicate. The

update included the reference number for the original log (reference 345).

120. At approximately 3.40pm, footage from a CCTV camera on Morrison Road in

Swanage shows Gaia running in the direction of Male A’s address.

121. At 3.42pm on 7 November 2017, Gaia’s aunt called Dorset Police to request

assistance.

122. She told the Call Handler that Gaia was a rape survivor, who had recently

been sent images that triggered an episode of mental ill health. She stated

that Gaia had just run out of her house “on some delusion, having

remembered some friend not far away, whose baby she thinks she’s carrying,

she’s not at all, I mean she hasn’t been in touch with this friend for months…”

123. Gaia’s aunt told the Call Handler she needed help to ensure Gaia attended

an appointment with her GP, regarding a referral to the Mental Health Team.

She then said she was about to go into another address (she did not say

where) in case Gaia was there.

124. The Call Handler offered to wait on the line to see if Gaia was there before

sending officers out. Gaia’s aunt replied, “I'm just checking, hang on... if I've

got no reply here I shall be returning home in case she's gone back to me.” At

this point the call ended; it is not clear whether this was because Gaia’s aunt

hung up, or because reception was lost.

125. At 3.50pm, the Call Handler recorded on log 345 from 2 November 2017 that

Gaia had just run out of the house. The same entry appeared on the duplicate

log, reference 160.

126. At 3.54pm, this information was passed to officers in the local area, along

with a description of Gaia.

127. Footage from a CCTV camera on Priests Road in Swanage shows Gaia

walking west towards the outskirts of town at approximately 3.59pm. This

footage was discovered on 19 November 2017, the day after Gaia was found

deceased.

128. Gaia’s aunt called Dorset Police again at 4.37pm, and spoke to Dispatcher A.

She explained that she was calling to check whether police were searching

for Gaia, as she had not heard anything. She stated that the previous Call

Handler had taken her number and told her somebody would call her

129. Dispatcher A asked Gaia’s aunt if she had called earlier to report Gaia

missing, and she replied that she had. Dispatcher A then took Gaia’s aunt’s

name, her location, Gaia’s name and age, and the time of her last call.

130. Dispatcher A clarified that Gaia’s aunt had called earlier to report Gaia

missing. Gaia’s aunt replied, “Well, just that she’d ran out and it’s a mental

health issue, we’ve got an appointment at the doctor’s at five o’clock, erm, to

refer to mental health services, and I was, I was going to pass on a message

that could they please take her straight to the medical centre in Swanage and

The previous Call Handler did not take Gaia’s aunt’s number, and did not tell her someone would

call her back.

I’ll meet them there, but I can’t get hold of anybody, and it really panics me

when I manage to get through and people say there’s no record, and I just,

my whole day’s been like this today.”

131. Dispatcher A then took further details, including a description of Gaia.

132. Gaia’s aunt informed Dispatcher A that Gaia was a survivor of rape, and was

“very mentally unwell” and suffering an “episode or decline”. She stated that

Gaia had run out of the house on impulse, and that her short-term memory

was very poor. She stated that Gaia had no phone with her, and no friends in

the area, and that she did not know where she might have gone.

133. Dispatcher A asked whether Gaia had ever self-harmed or attempted suicide

before, and Gaia’s aunt replied, “Not to my knowledge, not to my knowledge,

I mean she has, she’s very emotional at the moment, she’s got a lot of anger

inside her, a lot of upset, she did say, she did shout out this morning, “I hate

this life, which I haven’t heard before.”

134. Dispatcher A stated that she would try to find the record of Gaia’s aunt’s

earlier call “and broadcast it to see if we can get an officer to go round and

have a look around the town for her”.

135. Dispatcher A then informed Gaia’s aunt that she had found the log for her

earlier call, and that the reference number was 160. Following this, both

parties ended the call.

136. Dispatcher A did create a written record of this call, as per standard

procedure

. She summarised the call as follows:

“Further call re concern for niece Gaia pope aged 19. Inft has been out

searching for Gaia who has an appt at 1700 at Swanage medical centre to try

and obtain some help for MH issues. Inft has searched around the town,

Gaia’s HA in Langton Matravers, and has contacted the medical centre to see

if she has turned up for her appointment. Gaia does not have a phone, her

memory is poor and is currently mentally unstable. She has not previously

self-harmed as far as inft is aware, but is very angry and said 'i hate this life'

earlier today. Inft asking if there is any update from police. Please

rebroadcast desc.”

137. Dispatcher A graded the record as high priority, and categorised it as a

concern for welfare. She then linked the record to the duplicate log, 160.

However, she did not create a fresh incident log, and did not record any

details of the call on log 345 from 2 November 2017. Hers was the last entry

recorded on log 160.

138. At 4.52pm, Gaia’s mother called Surrey Police to report Gaia missing. Entries

on the Surrey Police log state:

 Gaia was last seen approximately ten minutes ago, at which time she

had said she was going to see Female B.

When a member of the public is put through to a call handler after calling 101 or 999, the call

handler will create a written record of that call even if it is not a police matter. If it is a police matter,

the call handler will create an incident log or a NICHE occurrence and the information will be

transferred across. If there is already a log open, a written record of the call will still be created and

the details added to the log.



She had been diagnosed with Post Traumatic Stress Disorder (PTSD)

following a rape, and had recently received “awful messages” and an

explicit image from the alleged rapist

online.

 She was psychotic, and had been sectioned numerous times in the

past. She was taking medication for her mental health issues.

 She posed a danger to herself, as she was epileptic and suffered from

chronic seizures.

 She was very emotional, and it was out of character for her to go

missing.

139. An entry on the Surrey Police log at 4.57pm states, “Dorset advised to email

this report over and it will be picked up urgently.”

140. At 4.58pm, Gaia’s aunt called Dorset Police again and stated:

“I want to know there’s somebody helping me find my niece. She’s got mental

health issues, she’s rushed out of the house, we need to get her to the

medical centre in Swanage who were expecting her at five o’ clock, but

they’re there till about six o’ clock. Erm, and she was last seen wandering up

[the street where Female B was living at the time].” She stated that this would

have been about an hour ago.

141. Gaia’s aunt reiterated that Gaia was a rape survivor and “very unwell”. She

stated that nobody had contacted her, she had not seen any police officers,

and she felt “completely in the dark”.

142. The Call Handler stated that they would update the incident with details of the

last sighting, and would “pass it on to our officers to make some further

enquiries in the area there”. The Call Handler further confirmed that Dorset

Police had been “making enquiries on the incident” and “contacting various

people”.

143. Gaia’s aunt asked if someone could call her back, and the Call Handler

confirmed that they would request this. They then ended the call.

144. At 4.59pm, Surrey Police forwarded the log of Gaia’s mother’s call to Winfrith

Control Room, marked as high importance.

145. At 5.02pm, a member of staff in Winfrith Control Room forwarded the Surrey

Police log to the Control Room Supervisor.

146. An entry on the Dorset Police log (reference 345) at 5.04pm states that

Gaia’s aunt had called again to say she believed Gaia was going to see

Female B.

147. A further entry at 5.15pm states:

“Email has been received from Surrey Police as Mispers

[sic] mother has

called in to them as she is in the London area at this time, reporting the same

- mother is nd can be contacted on they

The person who sent the messages and image was not the alleged rapist. Nonetheless, this

incident caused Gaia significant distress, and family members believe it contributed to her mental and

emotional state on the day of her disappearance.

It appears the intended meaning was: “Dorset advised us to email this report over” rather than

“Dorset was advised to email this report over”.

A police shorthand term for missing person.

believe that she [Gaia] may be at [Female B’s address], can we please ask a

unit to attend that address in the first instance before we record her as a

Misper. Email from Surrey has been attached to the occ.”

148. An entry at 5.20pm states that Constable B had spoken to Female B

, who

had said she had not heard from Gaia in years.

149. An entry at 5.25pm states:

“HSO

noted - can a call handler please be allocated to call the aunt who last

saw Gaia to complete a Misper RI [sic – RA, i.e. risk assessment] on a new

incident please.”

150. An automated entry at 5.31pm states:

“HSS

message received and dealing.”

151. An entry at 5.48pm states:

“Have called [Gaia’s aunt] to complete Misper RA but she advised me she

couldn't do it at that moment as she was on the phone to someone she

believed had a lead on where Gaia is. She states she will call back as soon

as she can to complete the RA.”

152. An entry at 6.11pm states that a new missing person log should be created

when Gaia’s aunt called back.

> Account provided by Dispatcher A

153. Dispatcher A provided a statement to the IOPC on 22 October 2019.

154. She stated that she formed the opinion Gaia’s aunt was calling to report a

concern for welfare, as she said she was calling about a mental health issue

rather than a missing person. She stated that, when she asked whether

Gaia’s aunt had reported Gaia missing earlier, she replied, “Well just that

she’d ran out and it’s a mental health issue, we’ve got an appointment at the

doctors at five o’ clock”.

155. She stated that she formed the opinion Gaia’s aunt was worried about Gaia

running around town and potentially missing her GP appointment.

156. She stated that she believed log 160 was the log relating to Gaia’s aunt’s

earlier call, as it included an entry referencing that call. She stated that she

recorded details of Gaia’s aunt’s call on this log, and requested that Gaia’s

details be re-broadcast for the attention of officers in the Purbeck area.

Occurrence (i.e. the incident log).

Female B and her father subsequently provided statements to Dorset Police. Female B’s father

stated that he and Female B went out to lunch at approximately 12.30pm on 7 November 2017,

following which she returned home and he went shopping. He stated that Female B was at home

when he returned at approximately 4pm, and that she went out to work at approximately 5.30pm, and

shortly after that, Gaia’s aunt came to the address looking for Gaia. Both confirmed Gaia did not come

to their house that day.

“HSO” or “HSS” is the code for the “top table” in the Control Room, where the FIC, the Deployment

Manager and the FIB24 DS sit.

See previous footnote.

157. She stated that she had received no training on missing persons or calls

reporting a concern for welfare.

> Account provided by the Control Room Supervisor

158. The Control Room Supervisor provided a statement to the IOPC on 18 June

2019.

159. He stated that he spoke to Gaia’s mother at 5.15pm, following receipt of the

email from Surrey Police, and she asked him to speak to Gaia’s aunt.

160. He stated that he then attached the email from Surrey Police to the pre-

existing log of 2 November 2017, and tasked an officer to speak to Female B.

He stated that he was subsequently told that Gaia was not with Female B,

and at 5.25pm, he requested that a risk assessment be undertaken. He

stated that he also alerted the Control Room “top table”, who picked up the

log at 5.31pm.

161. He stated that a missing person log was created at 6.18pm, and he added the

information from Surrey Police to the Reports tab on that log.

162. He stated that he was aware Surrey Police had graded the call as high risk;

however, Dorset Police had to complete their own risk assessment based on

information gathered by officers at the scene. He stated that he did not flag

the email to the Force Incident Commander (FIC), “because the risk

assessment was in hand”.

163. He stated that the FIC would have been aware of the information when he

completed the risk assessment, as he recorded his decision and rationale on

the log of 2 November 2017, as well as on the missing person log.

> Analysis of the evidence

164. At 3.42pm, Gaia’s aunt called Dorset Police to request help in ensuring that

Gaia attended a GP appointment. She explained that Gaia had just run out of

her house “on some delusion, having remembered some friend not far away,

whose baby she thinks she’s carrying, she’s not at all, I mean she hasn’t

been in touch with this friend for months…”

165. She provided some information about Gaia’s history, vulnerability and current

mental state, but overall, her comments to the Call Handler suggested that

she was not particularly concerned at that stage. She informed the Call

Handler that she was looking for Gaia at another (unspecified) address,

following which she intended to return home in case Gaia was there. The Call

Handler offered to wait on the line to see if Gaia was at the address before

sending officers out, but the call ended shortly afterwards.

166. At 3.50pm, the Call Handler recorded on a pre-existing log (relating to Gaia’s

complaint about being sent sexually explicit images) that Gaia had just run

out of the house. This information was passed to officers in the local area.

167. Because the Call Handler did not create a new log, Gaia’s aunt’s call was not

graded, no risk assessment was undertaken, and officers were not formally

tasked with making enquiries.

168. The College of Policing APP on Missing Persons states that anyone whose

whereabouts cannot be established will be considered missing until they are

located, and their well-being or otherwise confirmed. This definition has been

adopted by Dorset Police.

169. Dorset Police missing persons policy states that when someone is reported

missing, the Call Handler will create a missing person report and alert FCC

supervisors, who will then conduct an initial risk assessment and determine

whether the person is high, medium or low risk.

170. It was arguably apparent from Gaia’s aunt’s call at 3.42pm that Gaia’s precise

whereabouts were unknown. However, she mentioned various locations

where Gaia might have gone

. She also did not express any specific

concerns for Gaia’s wellbeing at that time, and the call recording indicates

that her primary concern was that Gaia might miss her GP appointment.

171. It will fall to the decision maker to consider whether Gaia should have been

treated as a missing person at this stage.

172. At approximately 3.59pm

, Gaia was caught on CCTV on Priests Road,

heading west towards the outskirts of town. This was the last verified sighting

of Gaia, before she was found deceased.

173. At 4.37pm, Gaia’s aunt called Dorset Police again, and spoke to Dispatcher

A. She stated that Gaia had run out of the house on impulse, and that she did

not know where she was. She explained that Gaia was a survivor of rape,

and was “very mentally unwell” and suffering an “episode or decline”, and that

her short-term memory was very poor. She further stated that Gaia had no

phone with her, and no friends in the area. Later in the call, she stated that

Gaia was very emotional and had “a lot of anger inside her, a lot of upset”,

and had shouted “I hate this life” that morning.

174. At one point during this call, Gaia’s aunt stated that she had called before to

report Gaia missing. While she did not explicitly say in her earlier call that she

wished to report Gaia missing, her use of this terminology was indicative of

how she perceived the situation by that point. It was also indicative of the

level of response she expected from Dorset Police.

175. When Dispatcher A clarified that Gaia’s aunt had called before to report Gaia

missing, she replied, “Well, just that she’d ran out and it’s a mental health

issue, we’ve got an appointment at the doctor’s at five o’clock, erm, to refer to

mental health services, and I was, I was going to pass on a message that

could they please take her straight to the medical centre in Swanage and I’ll

meet them there…”

Gaia’s aunt indicated that Gaia might be with Male A, and/or at the address she was about to enter,

or back at her home address.

This footage was only discovered after Gaia was found.

176. Dispatcher A stated that she would try to find the record of Gaia’s aunt’s

earlier call “and broadcast it to see if we can get an officer to go round and

have a look around the town for her”.

177. Dispatcher A then gave Gaia’s aunt the number for a duplicate log pertaining

to Gaia’s complaint of 2 November 2017.

178. Dispatcher A did not create a new log in respect of Gaia’s aunt’s call. As a

result, this call was not graded, no risk assessment was carried out, and

officers were not formally tasked with making enquiries. The evidence does

not indicate that any officers were tasked or dispatched as a result of this call.

179. Dispatcher A recorded details of Gaia’s aunt’s call on the duplicate log (which

had already been updated with details of the correct log), but not on the main

log of 2 November 2017. (Later, at 6.35pm, Dispatcher A recorded on the

missing persons log that Gaia had been very angry when she left the house,

and had shouted, “I hate this life.”.)

180. Dispatcher A explained that she believed Gaia’s aunt was only reporting a

concern for welfare, as her call related to a mental health issue, and when

she asked whether Gaia’s aunt had reported Gaia missing earlier, she

replied, “Well just that she’d ran out and it’s a mental health issue...” She

stated that she believed Gaia’s aunt was worried about Gaia running around

the town and potentially missing her GP appointment. She stated that she

believed log 160 was the correct log, as it included an entry referencing

Gaia’s aunt’s earlier call. She stated that she had received no training on

missing persons or concerns for welfare.

181. At 4.58pm, shortly after Gaia’s mother’s call to Surrey Police, Gaia’s aunt

called Dorset Police again. She stated that Gaia was a rape survivor and was

“very unwell”, and had last been seen about an hour ago. She asked if

anybody was out helping to look for her. She stated that nobody had

contacted her, she had not seen any police officers, and she felt “completely

in the dark”. The Call Handler stated that she would update the incident log

with details of the last sighting, and would “pass it on to our officers to make

some further enquiries in the area there”.

182. Again, the Call Handler did not create a new log, meaning that Gaia’s aunt’s

call was not graded, no risk assessment was carried out, and officers were

not formally tasked or dispatched.

183. The Call Handler also informed Gaia’s aunt that Dorset Police had been

“making enquiries on the incident” and “contacting various people”. In fact,

there was nothing on the log at that time to indicate that enquiries were being

made.

184. At 4.59pm, Surrey Police forwarded the log of Gaia’s mother’s call to Winfrith

Control Room, marked as high importance, and it was passed to the Control

Room Supervisor, who recorded an update on the existing log at 5.15pm. He

recorded that Gaia may be at Female B’s address, and requested that

officers attend that address before creating a missing person report.

185. At 5.20pm, Constable B updated the log to reflect that he had spoken with

Female B, with a negative result.

186. At 5.25pm, a Call Handler was allocated to contact Gaia’s aunt and create a

missing persons log. In the event, a log was not created until 6.15pm, as

Gaia’s aunt was initially unable to complete the risk assessment questions.

187. The evidence indicates that Constable B was the only officer undertaking

enquiries until approximately 9pm

, at which point Constables C and D were

asked to “keep a look out” for Gaia on their way back to Bournemouth (see

below). This was the extent of their involvement. Constables E and F were

then tasked with making some enquiries at approximately 1.23am, the other

three officers having finished their shifts some time ago.

188. It is hard to say whether the outcome might have been different if a missing

person log had been created at 4.37pm, because so little is known about

Gaia’s movements after she left Female A’s address. However, it is likely

that, if a missing person log had been created at 4.37pm, a more coordinated

approach would have been taken sooner, with better appreciation of risk and

of Gaia’s unique circumstances.

189. Gaia reportedly told Female A as she left that she was going to see Female

B. However, Female B lived south-east of the last known sighting of Gaia on

Priests Road. In other words, when Gaia was recorded on CCTV on Priests

Road, she was walking away from Female B’s house.

190. According to Female B’s father, Female B was at home during the period

between Gaia leaving Female A’s address and being caught on CCTV on

Priests Road, yet neither of them saw nor heard from Gaia that day.

191. Following the CCTV sighting on Priests Road at 3.59pm, it is possible, in her

confused state, that Gaia did head back into Swanage or take a more

circuitous route out of town. However, there is currently no evidence to

suggest that she did. No further CCTV footage of Gaia was found, and there

were no verified witness sightings.

192. If Gaia had continued heading out of town and made her way directly to the

location where she was later found, IOPC investigators estimated that she

could have arrived there by approximately 4.30pm, having conducted a timed

walk of the route between Priests Road and the Zig Zag coastal path

193. Constable F reported that the weather conditions were cold on that day, with

high winds. PolSA A subsequently recorded that weather conditions were

poor, with constant rain until 8pm. BBC weather data (see below) indicates

that the sun set at 4.32pm, and by 10pm, temperatures were expected to

drop to three degrees Celsius.

194. The Forensic Pathologist theorised (see elsewhere in the report) that Gaia

may have undressed as a paradoxical response to hypothermia. I do not

Excluding the search by NPAS, which took place between 8.40pm and 9.10pm.

have any data regarding how long it would take for a person to develop

hypothermia in these conditions, but presumably Gaia would have been at

heightened risk as it was wet and cold, and she was not wearing a jacket.

195. Gaia was also known to suffer from severe epilepsy, which was exacerbated

by stress. Her family stated that, even when taking daily medication, she

would have approximately ten seizures during the day and twelve during the

night. If she had been immobilised or impeded by seizures, in poor weather

without a coat, this could potentially have further increased her vulnerability to

exposure.

196. Finally, Female A reported that Gaia was visibly sweating and complaining of

feeling hot when she saw her at approximately 3.30pm. She stated that Gaia

stripped to her underwear, and had to be persuaded to get dressed again.

This raises the possibility that Gaia discarded her clothes simply because she

began feeling hot again, which could have happened relatively soon after she

reached the cliffs

. Without clothing, after sunset, at that time of year and in

the weather conditions described, Gaia would have been particularly

vulnerable to exposure.

197. In summary, we cannot rule out the possibility that Gaia followed a more or

less direct route to the area where she was found, and succumbed to

exposure within a relatively short timeframe.

198. If she had spent a significant period of time on open ground before moving

into the undergrowth, for example, if she had been disorientated and moving

slowly, then there would have been an increased likelihood of NPAS locating

her if they had been deployed sooner.

199. However, the evidence does not enable us to say how quickly Gaia reached

her final resting place, and the available evidence does not enable us to

express a view on whether a more timely police response might have resulted

in her being found alive.

200. It will fall to the decision maker to consider whether the initial calls to Dorset

Police were handled appropriately.

> The initial risk assessment

> Contemporaneous evidence

If Gaia had had no physical or mental health issues, it would in my view be very unlikely that she

would have discarded her clothing in inclement weather upon reaching the cliffs. The most likely

hypothesis in those circumstances would be that she had remained clothed until she developed

hypothermia and then started to discard her clothing. However, given that Gaia had been undressing

at Female A’s address and was unwell, it is not possible, in the absence of additional evidence, to rule

out that she resumed undressing upon reaching the cliffs (before becoming hypothermic).

201. At 6.15pm, Gaia’s aunt called Dorset Police to report Gaia missing.

202. Entries on the Dorset Police missing person log state that Gaia was mentally

unstable as the result of a rape two years ago, was taking medication for

epilepsy, and suffered from short term memory loss, which caused her to

become confused. It was further recorded that she did not have a mobile

phone with her, and may not have any money.

203. At 6.35pm, Dispatcher A recorded on the log that Gaia had been very angry

when she left the house, and had shouted, “I hate this life.”

204. An entry at 6.55pm states that Dorset Police had previously dealt with Gaia

on 21 October 2017, after she left Poole Hospital despite “needing sectioning”

and started screaming at members of the public outside. The entry states that

Gaia was suicidal on this occasion.

205. In addition to the above, the following additional relevant information was

recorded on the pre-existing log of 2 November 2017:

 Gaia had recently received sexually explicit messages and images

from a male on Facebook, which caused her distress and brought up

memories of the rape.

 She had run out of the house at approximately 3.50pm.

 She was delusional, and believed she was pregnant by an old friend,

possibly as the result of a flashback.

 Gaia’s mother had also contacted Surrey Police to report Gaia missing,

and the email from them was attached to the log.

206. At 6.58pm, FIC A recorded the following entry on the log of 2 November

2017:

“Initial missing review. I have conducted an initial review of the details of this

missing person contained within the risk assessment and the command and

control incident log. Based on this alongside the APP for missing persons I

am initially grading this missing person as medium risk. The risk of harm to

the subject or the public is assessed as likely but not serious.

The missing person is vulnerable due to being mentaly [sic] unstable and

highly emotional as a result of a rape 2 yrs ago. She also suffers epilepsy for

which she takes medication, short term memory loss and flashbacks. She is

struggling to deal with the rape matter and is currently receiving councelling

[sic] to assist with this. She has also been the victim of inapprorpaite [sic]

messages and images being sent via FB messenger which has sparked the

flashbacks to the rape incident. This category requires an active and

measured response by police and other agencies to trace the missing person

and support the person reporting. Critical Incident Inspector to oversee

enquiries and review risk and enquiries once full details have been obtained.”

207. At 7.01pm, FIC A recorded the same entry on the missing person log.

208. A further entry by the Critical Incident Inspector at 1.24am on 8 November

2017 states:

“I have reviewed this misper and the previous incident. I am upgrading misper

to****high risk*** in view of missing her medication and may [sic] have

collapsed.”

> Account provided by the Team Deployment Manager

209. The Team Deployment Manager provided a statement to the IOPC on 10

April 2019. She explained that she, the FIC and the Force Intelligence Bureau

DS were collectively known as the “top table”, and held overall responsibility

for managing incidents that had a significant level of threat, risk and harm,

including missing person reports.

210. She stated that the Call Handler transferred the log to the top table at

6.34pm, and FIC A picked it up at 6.48pm. She stated that she and FIC A had

an agreement that they would share missing person reviews, and that

whoever picked up the log first would take ownership.

211. She stated that FIC A passed the incident to the Risk Management Unit

(RMU) at 6.53pm, and graded Gaia as medium risk at 7.01pm.

> Account provided by the Critical Incident Inspector

212. The Critical Incident Inspector provided a statement to the IOPC on 25

January 2019. He stated that his shift started at 6.30pm on 7 November

2017, and initially his time was taken up in dealing with custody issues and a

high-risk missing person.

213. He stated that he became aware of the incident log relating to Gaia at

approximately 1.16am, and on reviewing the log, he formed the impression

that it should be upgraded immediately to high-risk. He stated:

“I did feel that even with the initial information this should have been the

grading when the log was opened. I was also concerned that [due to] the time

lapse and without having had the correct oversight, it would be difficult to

progress quickly, given the resourcing levels past midnight…

[I have] previously expressed concerns as have my colleagues around the

incident allocation procedure when allocating messages

to Operational

Critical Incident Inspectors and in the past it would not be rare to see up to 15

allocated unread incident messages at the end of a shift to mispers and other

incidents, that really should have been past [sic] directly by radio in order to

advise us. I am aware that the Force has restructured the role and this may

have been rectified.”

> Missing Person training in Dorset Police

The Risk Management Unit (RMU, now known as FIB24) is based in the Dorset Police Control

Room. Their role is to research intelligence relating to incidents and individuals.

“Message” in this context refers to police incident logs.

214. The Dorset Police Performance Budget and Projects Officer has advised that

Dorset Police moved to a new training system in 2010, following which the old

system was archived as a “display only” feature on the force HR system.

215. She stated that, due to a system fault, a person’s training history on the old

system may include training courses that they had not attended. She

explained that it was currently not possible to access the system to

interrogate the data and ascertain what training officers did attend prior to

2010.

216. The available training records indicate that some officers were required to

complete training packages provided by the National Centre for Applied

Learning Technologies (NCALT); however, not all officers completed these

packages.

217. FIC A’s training record shows that he was required to complete an NCALT e-

learning training package titled, “Public Protection - Missing Daughter”, but

did not do so.

218. Dorset Police Professional Standards Department (PSD) has advised that

officers do not face repercussions if they fail to complete NCALT training.

> Account provided by former Force Incident Commander (FIC)

A (now retired)

219. FIC A provided a statement to the IOPC on 3 June 2019.

220. He stated that, at the time Gaia went missing, he had been an FIC for

approximately seven years and was regarded as one of the most experienced

FICs in Dorset.

221. He stated that there was limited on-the-job training when he first started as

FIC, but that new FICs were required to complete an initial week-long Tactical

Firearms Commander training course focusing on incidents where there was

a high level of risk. He stated that he then shadowed another FIC for a few

shifts, and started performing the role once he was considered competent.

222. He stated that one of his duties as FIC was to undertake an initial

assessment of new missing person reports. He stated that, when doing so, he

would assess the available information with reference to the NDM and

College of Policing guidance. He stated that he was fully aware of the College

of Policing missing person risk categories, and believed that he had an

“excellent” knowledge of them and the ability to apply them.

223. He stated that he would only grade a missing person as high risk if there was

an immediate and real danger of that person coming to very serious,

potentially fatal harm. He stated that this could include (but would not

necessarily be limited to) a missing person who had left a suicide note, a very

young child with no understanding of danger, or an elderly person with

dementia.

224. He stated that in Gaia’s case, he reviewed all of the available information and

noted that Constable B was already aware of the situation and was

undertaking enquiries.

225. He stated that he was aware that Gaia was reportedly not in possession of a

mobile phone, and had shouted, “I hate this life” as she left

. He stated that

he did not perceive that comment as a threat to take her life, but rather as “an

expression of her opinion of how she viewed her life”.

226. He stated that he had no reason to doubt his risk assessment, and having

reflected on the incident, he still believed he had made the correct decision

based on the information that was available to him at that time.

227. He stated that he was not aware of the email from Surrey Police (in which

Gaia was graded as high risk) when he completed his initial risk assessment,

and there was no mention of that email on the log

228. He stated that if he had been aware of that email, it may “potentially” have

affected his decision, and he “may” have graded Gaia as high risk.

229. He explained that the Critical Incident Inspector would carry out a further

review of the FIC’s initial risk assessment if the missing person had not been

located following the initial visit by officers.

230. He confirmed that it would have been his responsibility to make the Critical

Incident Inspector aware of the log. He stated that it appeared he had not

done so, which appeared to be an oversight by him; however, he had

recorded an instruction on the log to this effect at 7.03pm (see below) and the

Dispatcher or “Buddy” would normally ensure that any actions or tasks were

implemented.

> Case review by the College of Policing

231. The IOPC asked the College of Policing to comment on whether the initial risk

assessment and subsequent review were appropriate. A review was

undertaken by a Sergeant from the Police National Search Centre (PNSC).

His findings and conclusions are outlined in a report dated 15 October 2018.

Among other things, he observed that:

 FIC A conducted the initial risk assessment, in accordance with the

Dorset Police Missing Person Policy. However, the next documented

review (by the Critical Incident Inspector) took place just over six hours

later. If this was the first review of the initial risk assessment, then it was

not conducted in accordance with force policy (which states that the

review should take place within six hours).

 The initial risk assessment of medium was “flawed” and “questionable”

in light of Gaia’s known mental health issues, her severe epilepsy, the

As outlined previously, Gaia had in fact said this earlier that morning, but FIC A could only rely on

the information that was available to him at the time.

An audit was undertaken at the IOPC’s request [T81] which confirmed that FIC A had not accessed

the email from Surrey Police via Niche. The Computer Audit Officer commented, “The fact that the

email came into the FCC generic inbox at 16:59hrs on 7

Nov 2017 and forwarded from the FCC

inbox direct to [the Control Room Supervisor] at 17:02hrs, means that [FIC A] could have reviewed

the email in the FCC inbox before moving it through to [the Control Room Supervisor]… [or] he

may have seen the wording of the email in the indent [sic] log or OEL / misper report is [sic] the text

has been repeated / copied to these documents.”

recent inappropriate Facebook messages, her mental and emotional

state at the time of her disappearance, and finally the fact that it was

cold, wet and dark, and she was not dressed appropriately for the

weather conditions.

 The Dorset Police Missing Persons Policy does not include the category

of “Missing Persons who are Ill or Injured”, as per national guidance. If

this category had been included in the policy, it may have assisted with

the risk assessment, as Gaia had physical and mental health issues.

 Overall, Dorset Police Missing Persons Policy contains a number of

inconsistencies and contradictions, and uses terms such as “consider”

and “where required”, which are unclear and potentially confusing. The

PNSC Sergeant recommended an immediate review of the policy, with

input from appropriate subject matter experts.

> Analysis of the evidence

232. FIC A assessed Gaia as medium risk at 6.58pm on 7 November 2017. At

1.24am on 8 November 2018, the Critical Incident Inspector upgraded the

assessment to high risk on the grounds that Gaia had not taken her

medication, and may have collapsed.

233. Gaia’s family complained that Dorset Police should have recognised early on

that she was high risk, as they knew she was vulnerable.

234. They alleged that the initial risk assessment was influenced by assumptions

stemming from the rape investigation, and expressed their belief that Gaia

might have been found alive if she had been treated as high risk from the

outset.

235. This investigation has not identified any evidence to suggest that the initial

risk assessment was influenced by the rape investigation. FIC A was not

involved in that investigation, and did not reference it in his rationale at the

time, or in his subsequent statement. (As outlined in the report pertaining to

the rape investigation, the IOPC also found no evidence to support a finding

that the officers who investigated Gaia’s allegations were influenced by

assumptions or prejudices about her.)

236. As to whether FIC A’s risk assessment was appropriate: the APP states that

a missing person should be graded as high risk if the risk of serious harm is

deemed very likely, and as medium risk if the risk of harm is deemed likely

but not serious. The APP defines a risk of serious harm as, “A risk which is

life threatening and/or traumatic, and from which recovery, whether physical

or psychological, can be expected to be difficult or impossible.” In this

respect, Dorset Police policy mirrors the APP.

237. The following information was available on the missing persons log at the

time of FIC A’s risk assessment:

 Gaia was mentally unstable as the result of a rape two years ago, was

taking medication for epilepsy, and suffered from short term memory

loss, which caused her to become confused.

 She did not have a mobile phone with her, and potentially did not have

any money.

 She had been very angry when she left the house, and had shouted, “I

hate this life.”

 Less than a month before, police were called after Gaia left Poole

Hospital despite “needing sectioning” and started screaming at

members of the public outside. Gaia was suicidal on this occasion.

238. The following additional relevant information was recorded on the log of 2

November 2017:

 Gaia had recently received sexually explicit messages and images from

a male on Facebook, which caused her distress and brought up

memories of the rape.

 She had run out of the house at approximately 3.50pm.

 She was delusional when she left the house, and believed she was

pregnant by an old friend, possibly as the result of a flashback.

 Gaia’s mother had contacted Surrey Police to report Gaia missing, and

the email from Surrey Police was attached to the log.

239. In addition to the above, FIC A could reasonably be expected to have been

aware that it was dark, and that the weather was poor, and that temperatures

were low at night, due to the time of year.

240. FIC A recorded his rationale as follows:

“The missing person is vulnerable due to being mentaly [sic] unstable and