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         Police Service of Northern Ireland
          The purpose of this Service Procedure is to provide guidance on how police officers
          investigate those deaths where the cause of death is not immediately known. Our
          aim is to ensure that all suspicious deaths are treated as a potential murder
          investigation until the contrary is established



HQ Ref: TRIM 301737

                                           SP 30/2004

                               SERVICE PROCEDURE


       POLICE INVESTIGATIONS INTO UNEXPECTED,
         UNEXPLAINED OR SUSPICIOUS DEATHS


1.   SERVICE PROCEDURE IDENTIFICATION


     SERVICE PROCEDURE TITLE:                      Police Investigations into Unexpected,
                                                   Unexplained or Suspicious Deaths

     PROCEDURAL OWNERSHIP:

          DEPARTMENT                               Operational Support Department
          BRANCH                                   Operations Branch

          AUTHOR                                   Inspector, Operational Policy and
                                                   Support

     PROCEDURE APPROVED BY:                        ACC, Operational Support Department

          CCF REF/OTHER
          DATE OF APPROVAL

     IMPLEMENTATION DATE:                          23 January 2007

     DATE OF ISSUE:                                23 January 2007

     AMENDED AND REISSUED:                         7 May 2010

     REVIEW DATE:                                  8 May 2011
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                                             INDEX

Section                                     Subject                                 Page


  1       Service Procedure Identification Page                                      1


  2       Aim of Service Procedure                                                   3


  3       Introduction                                                               3
 3(1)     Executive Summary                                                          3
 3(2)     Origin                                                                     3
 3(3)     Application                                                                3


  4       Legal Basis                                                                3


  5       Policy Links                                                               3


  6       Consultation                                                              3-4


  7       Human Rights/United Nations Convention on the Rights of the Child          4
          (UNCRC)/Equality/Code of Ethics/Freedom of Information

   8      Procedure and/or Guidance                                                  4
  8(1)    First Officer at the Scene                                                 4
  8(2)    Scene Preservation                                                         5
  8(3)    Level of Investigation and Appointment of an Investigating Officer (IO)   5-6
  8(4)    Assistance from a Pathologist                                              6
  8(5)    Photographic Record of the Scene                                           6
  8(6)    Interview Family of Deceased                                               6
  8(7)    Coroner Notified                                                           7
  8(8)    Who Else Should Be Notified?                                               7
  8(9)    Domestic Abuse                                                             7
 8(10)    Removal of Remains From The Scene                                          7
 8(11)    Post Mortem                                                                7
 8(12)    Post Mortem Examination Log – Form P2                                      8
 8(13)    Briefing the Pathologist                                                   8
 8(14)    Discuss Autopsy Findings With Pathologist                                  8
 8(15)    Forensic Samples                                                           9
 8(16)    Who Continues the Investigation?                                           9
 8(17)    Result of Tests                                                            9
 8(18)    Receipt of Post Mortem Report                                              9
 8(19)    Reporting to the Coroner                                                   9
 8(20)    Non Suspicious Death                                                      10
 8(21)    Sudden Death Register                                                     10
 8(22)    Death in Prison                                                           10


  9       Monitoring/Review                                                          10



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2.   AIM OF SERVICE PROCEDURE

     The aim of this Service Procedure is to ensure that all suspicious deaths are treated as a potential murder
     investigation until the contrary is established.

3.   INTRODUCTION

     (1) Executive Summary

         This Service Procedure seeks to give guidance on how police officers investigate those deaths where
         the cause of death is not immediately known.

     (2) Origin

         The driver for this Service Procedure is found in the European Convention for Human Rights (ECHR)
         Article 2 (the right to life) where police officers are obliged to carry out an effective official
         investigation when there is reason to believe that an individual has died or sustained life threatening
         injuries in suspicious circumstances. Where death results the essential purpose of such an
         investigation is to secure the effective implementation of the domestic laws that protect the right to
         life. The investigation must be capable of establishing the cause of the injuries and the identification
         of those responsible with a view to their punishment. An investigation will only be considered
         effective where the authorities can show that they took all reasonable steps to secure the evidence
         concerning the incident.

     (3) Application

         The Coroner has the responsibility for investigating an unexpected or unexplained death or a death
         attended by suspicious circumstances (Section 8 of the Coroners Act 1959). To assist in this task
         the Coroner calls on the police to undertake the preliminary investigation to allow a decision on
         whether a post mortem should take place and whether or not an inquest is necessary. This Service
         Procedure applies to all police officers who act as an agent of the Coroner and attend the scene of
         an unexpected, unexplained or suspicious death.

4.   LEGAL BASIS

     The Coroners Act (NI) 1959, as amended, and the Coroners (Practice and Procedure) Rules (NI) 1963, as
     amended, are the legal basis for this Service Procedure.

5.   POLICY LINKS

     This Service Procedure should be read in conjunction with Service Procedure No 47/04 - Duties of
     Personnel Attending A Serious Crime Scene and Service Procedure No 22/05 - Child Protection - Case
     Management Reviews. Reference should also be made to “Working with the Coroner-Best Practice
     Guide” available on PoliceNet (Home Page-Ops Support-Operational Policy & Development).

6.   CONSULTATION

     Consultation has taken place with the following:

     (1) Coroners Service for Northern Ireland;

     (2) Police Ombudsman for Northern Ireland;

     (3) Human Rights Legal Adviser;

     (4) Crime Operations;



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     (5) Scientific Support;

     (6) District Occurrence Case Management (OCMT) Managers;

     (7) Criminal Justice Department;

     (8) Senior Forensic Medical Officer (FMO).

7.   HUMAN RIGHTS/UNITED NATIONS CONVENTION ON THE RIGHTS                                  OF    THE     CHILD
     (UNCRC)/EQUALITY/CODE OF ETHICS/FREEDOM OF INFORMATION

     (1) This Service Procedure is deemed to be Human Rights compliant, consideration has also been given
         to the United Nations Convention on the Rights of the Child (UNCRC). Police officers should be
         aware of Article 9 Human Rights Act “Freedom of Thought, Conscience and Religion” when attending
         the sudden or unexplained death of a member of another ethnic group. Police officers are advised to
         consult “A Guide to Culture and Diversity in Northern Ireland”, available through “search the intranet”
         on PoliceNet for further guidance.

     (2) This Service Procedure has been screened for Section 75 considerations and complies with the
         PSNI Code of Ethics. This Service Procedure is suitable for public disclosure in accordance with the
         Freedom of Information Act 2000.

8.   PROCEDURE AND/OR GUIDANCE

     (1) First Officer at the Scene

         The responsibility of the first officer at the scene of an unexpected, unexplained or suspicious death
         is to:

         (a) Preserve life (summon medical assistance if appropriate);

         (b) Task a doctor to pronounce life extinct. If a deceased’s own doctor is not available then the
             local on call out of hours doctor should be contacted. Control rooms should have details of the
             local out of hours doctor. A FMO should only be contacted to certify life extinct at the scene of a
             confirmed suspicious death (including a death following police contact). Minimum disruption
             should be caused to the scene as the FMO certifies life extinct. A pathologist will confirm cause
             of death at any subsequent post mortem.

         (c) Maintain the scene;

         (d) Establish the facts and circumstances surrounding the death.

         (e) Ensure the death has been reported to the Coroner.




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(2) Scene Preservation

    (a) Initial police response to the scene of an unexpected, unexplained or suspicious death should
        be prompt and controlled. As far as possible the scene should not be disturbed until the facts
        surrounding the death have been established. This would include the body, which should not be
        removed until the investigations at the scene are complete. This is to preserve evidence should
        it later become necessary to direct a full forensic examination of the scene. Major
        Incident/Serious Crime Scene Log, Form 38/15, should be opened and the integrity of the scene
        preserved. Ideally, the log officer should have previous experience of completing a scene log,
        however if this is not possible, the officer in charge of the scene must provide appropriate
        supervision and guidance. Service Procedure No 47/04 - Duties of Personnel Attending a
        Serious Crime Scene contains instruction in the completion of Serious Crime Scene Logs.
        Scene Log Officers should consult with the senior officer at the scene in relation to requests
        from persons wishing to enter the scene eg a priest wishing to administer last rites. All such
        requests will be considered individually and if a decision is made to allow entry, full forensic
        protection will be required.

    (b) The decision to close the scene should only be taken by a supervisory officer who is fully
        satisfied that the examination is complete. It is recognised and accepted that sometimes a
        scene may have to be reopened for further examination but this is not as desirable as a single
        complete examination. Therefore before the decision to close a scene is taken the supervisor
        directing closure should consult with the appropriate personnel, such as Criminal Investigation
        Department (CID), Child Abuse Investigation Unit (CAIU), Crime Scene Investigator (CSI)/Crime
        Scene Manager (CSM) or other professionals who could provide an expert view. Where a post
        mortem is to be conducted, serious consideration should be given to holding the scene until
        such an examination is complete; this should be a particular consideration where death has
        occurred in an establishment with any duty of care towards the person staying in it eg a prison,
        school or other such public or private establishment.

(3) Level of Investigation and Appointment of an Investigating Officer (IO)

    (a) A Sergeant must actually attend the scene of every death. Please note that this requirement
        has been reinforced by PONI. The Sergeant should be satisfied as to the proper extent of the
        police enquiries being made or required to be made into the incident and make an initial
        assessment as to the nature and cause of death. The investigation must include carrying out
        house-to-house and local enquiries at the time, before making a final assessment. A record
        must be kept of the enquiries made. Only in exceptional circumstances should these enquiries
        not be carried out at the time. The Sergeant making such a decision must have good grounds
        for doing so.

    (b) If the Sergeant considers that the death cannot be explained or appears suspicious an
        experienced CID officer must attend the scene.

    (c) Where a cot death is involved, a CAIU officer from the District Public Protection Unit (PPU) must
        also attend. [Directions contained in Service Procedure No 2/2010 - Sudden Unexplained
        Death in Infancy (SUDI) must be adhered to]. CID called to the scene of a death will carry out
        further enquiries to both establish a possible cause of death and whether there are any
        unexplained or suspicious circumstances which may suggest the commission of a criminal
        offence. If such circumstances arise, the scene must be preserved and held pending the
        outcome of a post mortem examination and further investigation. CSIs and photography should
        be asked to attend. Consideration should also be given to the need for mapping section to
        attend and to the appointment of a Family Liaison Officer if a crime is suspected.

    (d) Officers should also be mindful of the procedures in instances of a death in police custody or a
        death following police contact. See Policy Directive 04/09 – Policies and Procedures relating to
        the Police Ombudsman for Northern Ireland (PONI).


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    (e) The Sergeant, following consultation with the detective at the scene, will conclude whether the
        death is considered unexplained or suspicious. If the death is considered unexplained or
        suspicious a Detective Inspector should be immediately tasked to attend the scene. A clear
        record must be kept of who is in charge of the investigation at each stage.

    (f)   In appropriate cases (deaths in the workplace etc) the Investigating Officer (IO) must also notify
          the Police Service of Northern Ireland Health and Safety Branch at Lisnasharragh. The out of
          hours ‘On Call’ Health and Safety Adviser can be contacted through Belfast Regional Control
          (BRC). The ‘On Call’ Health and Safety Adviser will notify and liaise with the Health and Safety
          Executive Northern Ireland (HSENI), government enforcing agency for Health and Safety.

    (g) If it is concluded that the death is not unexplained or suspicious, the Sergeant will appoint a
        uniform officer to inform the Coroner, conduct the investigation and to attend any post mortem.
        This officer will also prepare an inquest file, if called for by the Coroner. District OCMT offices
        have appointed a member of staff to supervise the preparation of inquest files and officers
        should make themselves aware of what is expected of them. The IO’s Sergeant will be
        responsible for ensuring that a proper investigation is conducted. An inexperienced officer
        should not be appointed to conduct such an investigation without a high level of supervision.

(4) Assistance from a Pathologist

    The duty pathologist may be contacted for advice concerning any unexplained or suspicious death
    under investigation. Such requests should be made through the callout desk at either BRC Urban
    Region or via local communication centres Rural Region. The officer in charge of the investigation
    must actually speak, per telephone, to the pathologist requesting attendance at the scene of the
    unexplained or suspicious death. If this is not possible then the person who speaks to the pathologist
    must have attended the scene and have sufficient knowledge of the reasons why a pathologist
    should attend to examine the body in situ. Where the death is suspected to be a homicide,
    consideration should be given for the attendance of a pathologist.

(5) Photographic/Video Record of the Scene

    Photographs should be taken of the scene under direction of the IO with special emphasis on areas
    where the injury occurred (eg where it is alleged the person fell down the stairs, where ligatures were
    used in a suspected suicide case). A video of the scene should be considered to facilitate the
    pathologist in their examination/interpretation as to the cause of death. The IO will weigh up the
    benefits of such action against potential loss of evidence from the scene. Any requests from a
    pathologist at the scene for photographs to be taken should be complied with.

(6) Interview Family of Deceased

    The family of the deceased will be spoken to as a priority in all unexplained or suspicious deaths in
    order to establish any problems, comments or circumstances, which may be relevant to, or
    surrounding the death. Even when a doctor is prepared to issue a death certificate, the IO must still
    speak to the deceased’s family as soon as possible to facilitate any concerns the family may have
    surrounding the death. Police must record accurate notes in their notebooks at the time all such
    enquiries are made. All efforts should be made by the IO to establish the identity of the next of kin
    and communicate this information accurately to the Coroner. This is particularly important to assist
    the Coroner when deciding to whom the body should be released after a post mortem.




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(7) Coroner Notified

    The IO will notify the Coroner’s Office about the death as soon as possible, after an initial
    assessment has been made and before the post mortem is arranged. Normally, the Coroner should
    be contacted prior to the removal of a body from the scene. Currently HM Coroner does not require
    to be contacted unless there is a particular issue to be addressed. A Form 19 (Police Report
    Concerning Death) should be completed and promptly submitted in all cases. A copy of the Form 19
    must be emailed to the relevant District OCMT office. The Coroner’s Office will provide a Coroner’s
    Liaison Officer who will contact the family of the deceased and liaise with them and other agencies in
    relation to release of remains etc. The Coroner’s Office can be contacted on 028 9044 6800 with an
    on-call service operating out of hours from the same number.

(8) Who Else Should Be Notified?

    (a) The IO must brief the local duty officer as soon as practicable on the initial findings. Where the
        death is considered suspicious the IO must initiate a pro-forma email through their District Call
        Management reporting the death to BRC.

    (b) In relation to the death of a Foreign National, contact the PSNI Extradition Unit based at
        Knocknagoney who will advise on contacting the relevant Embassy.

(9) Domestic Abuse

    IOs should, where relevant, look for a previous history of domestic abuse. This should include
    examining the Domestic Abuse Register, contact with the Domestic Abuse Officer and Community
    Policing Team.

(10) Removal of Remains From The Scene

    When the body of the deceased is ready for removal from the scene, the family may volunteer the
    name of an undertaker to transport the body to the mortuary if applicable. If no specific undertaker is
    nominated, local police should operate a call-out rota for their area. In Belfast, the details of the
    contracted undertaker (currently Wrays) are held at BRC. Outside the Greater Belfast area, there is
    no requirement to task the contracted undertaker to homicide scenes as any undertaker will perform
    this function. They should however be advised by the Senior Investigating Officer (SIO) on the
    correct method of placing the body in the body bag to preserve evidence. In circumstances where
    there is no suspicion of a crime having been committed but the body has to go to the mortuary
    pending a decision re the issue of a death certificate, police are not required to accompany the body.
    They must however complete a mortuary admission sheet (Form P4-NI Regional Forensic Mortuary
    Admission Sheet available on PoliceNet) which accompanies the body to the mortuary. In
    circumstances where the deceased has been suffering from a terminal illness and it is not possible to
    get a death certificate issued (after hours etc), the Coroner’s Office advises that the remains may be
    moved to an undertakers with the proviso that they are not disturbed (clothing removed/embalmed
    etc) until a death certificate is issued.

(11) Post Mortem

    The IO must attend the post mortem. If for any reason this is not possible, the supervising officer
    must ensure that a fully briefed deputy attends. If a FMO attended the scene, a copy of their report
    must be obtained and brought by the IO or deputy to the post mortem. Every effort should be made
    to ensure that photographs of the scene are also brought to the post mortem. Where possible the
    same CSI and photographer who attended the scene should also attend the post mortem. The IO or
    nominated deputy should direct the CSI/photographer as to the extent of any samples/photographs to
    be taken. All post mortems are conducted at the Northern Ireland Regional Forensic Mortuary based
    at the Royal Victoria Hospital, Belfast.



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(12) Post Mortem Examination Log – Form P2

    (a) The post mortem examination and associated recovery of potential evidence types should be
        conducted and viewed as a crime scene. The crime scene assessment process concentrates
        upon the relationship between the various elements including scene forensics and post mortem
        examination and if undertaken in a rigorous professional manner can be highly influential in the
        development of subsequent effective lines of enquiry.

    (b) The purpose of the post mortem log, Form P2 is to maintain a detailed and contemporaneous
        written record of the post mortem examination. The importance of detailed and accurate note-
        taking cannot be overemphasised. The log officer must include the accurate recording of all
        actions and preliminary cause of death. The post mortem examination log will only be
        completed in cases of unexplained, suspicious death and murder.

    (c) The Senior CID IO will nominate a Log Officer who is not involved in the recovery of evidence
        types associated with the post mortem examination. The log officer will be responsible for
        completing all sections of the post mortem log and ensuring the guidance notes on the front
        cover of the log are complied with.

    (d) As for other crime scene logs, upon completion of the post mortem examination, the log officer
        will as soon as practicable give the completed post mortem log to the IO for perusal and
        inclusion in the investigation papers.

(13) Briefing the Pathologist

    A pathologist is appointed by the Coroner and acts under the instructions of that Coroner. The IO
    should tell the pathologist carrying out the post mortem the layout of the scene, circumstances in
    which the deceased was found, the result of the initial enquiries and identify areas of concern. The
    pathologist should be provided with a completed Form P1 (Details Required For Coroners’ Post
    Mortem Examinations). The IO should also be in possession of the deceased’s medical history to
    present to the pathologist. A clinical summary from the deceased’s GP is all that is required. Full
    medical notes are no longer required unless specifically requested by the pathologist or the Coroner.
    It is also important that the IO is in a position to provide the pathologist with details of particular
    issues or suspicions that the police officer wishes the post mortem to clarify. Where the pathologist
    requests copies of statements, maps or video, then these must be provided as soon as practical. It is
    particularly important in relation to cot deaths where information on the family environment, parents’
    demeanour and account provided, leading up to the infant’s death should be brought to the
    pathologist’s attention prior to the post mortem. The thoroughness of such investigations should be
    accompanied with sensitivity to avoid undue stress.

(14) Discuss Autopsy Findings With Pathologist

    (a) The IO attending the post mortem will remain readily available at the mortuary to consult, where
        appropriate, with the pathologist during the autopsy of the body and to discuss findings at the
        end of the post mortem.

    (b) The IO will notify these findings directly to their supervisor and the Coroner. It is of key
        importance that the police officer understands the autopsy findings and gets a Preliminary
        Cause of Death Form signed by the pathologist. If the officer is unsure of medical terms used,
        an explanation must be requested. The Preliminary Cause of Death Form (C1) must be
        delivered or faxed to the Coroner’s Office before leaving the mortuary. A copy of this form
        must be kept and included in the inquest file.




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(15) Forensic Samples

    Any samples taken by the pathologist to assist in establishing the cause of death and handed to the
    IO or representative must be delivered promptly to the Forensic Science Northern Ireland (FSNI) in
    accordance with current Service instructions.

(16) Who Continues the Investigation?

    Following a post mortem which establishes that the death was due to natural causes and no
    suspicion remains, the investigation on behalf of the Coroner will be continued by a uniform officer.
    However, the investigation will not be returned to a uniform officer until it has been discussed at
    Detective Inspector and Duty Inspector level and agreement is reached that this would be
    appropriate. In such cases a written summary of the investigation to date, together with relevant
    documents, should be handed to the Duty Inspector. The relevant Command and Control entry must
    be updated by CID to reflect that this death is no longer considered suspicious and must include the
    name of the inform IO.

(17) Result of Tests

    Where the cause of death is dependent on further tests at the pathology or forensic laboratories then
    the results must be brought to the immediate attention of an officer of Inspector rank who will direct
    any subsequent enquiries. The IO should also make the pathologist aware of these results.

(18) Receipt of Post Mortem Report

    (a) The State Pathologist’s Office will write to each IO to inform them that a report of the post
        mortem was forwarded to the Coroner and also gave the cause of death. The District
        Commander can request a copy of the pathologist’s report for police purposes. The IO is
        advised by the State Pathologists’ Office to contact the Coroner’s Office for further instructions
        on receipt of the summarised post mortem report.

    (c) Normally an inquest file should not be submitted without a post mortem report. On occasions a
        long delay on the availability of a report may be encountered. In such cases the inquest file
        should be submitted highlighting this difficulty and requesting the Coroner’s assistance in
        obtaining and supplying a copy of the post mortem report. Officers should keep lines of
        communication with Coroner’s Liaison Offices open while preparing an inquest file. Officers
        should also be aware that a working practice agreement exists between the Coroner’s Service
        and PSNI in relation to late file submission.

(19) Reporting to the Coroner

    (a) When requested by the Coroner, the District Commander, or an Inspector/Sergeant acting on
        behalf of the District Commander, will ensure that the investigation has been satisfactorily
        completed and will forward copies of the manuscript/statements to the Coroner’s Office. After
        editing by the Coroner, a typed copy will be returned to the District Commander.

    (b) The Coroner will notify the relevant OCMT and Ops Planning office of the inquest date and
        necessary witnesses. Prior to witness invitations being issued, the Coroner will write to the next
        of kin, notifying them of the inquest date. Following the inquest, the Coroner will return the copy
        Deposition Forms together with the verdict to the OCMT for retention.




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     (20) Non Suspicious Death

         In cases where the cause of death has been established, and where death was due to natural
         causes and no suspicion remains, the Coroner may then decide that an inquest is unnecessary.
         Subsequently, the Coroner will give formal notice to the Registrar of Deaths of the decision. In such
         cases the investigation papers, including details of the initial police response, should be retained by
         the OCMT and only ‘weeded' in line with current Policy.

     (21) Sudden Death Register

         The relevant details surrounding the cause of death should, following the post mortem, be included in
         the Sudden Death Register for the District concerned which should be updated as the investigation
         progresses. The Sudden Death Register is normally electronic and maintained by OCMT on the
         ‘G’ Drive. Each District OCMT office will have a member of staff responsible for inquest file
         submission and for updating the sudden death register.

     (22) Death in Prison

         Where a death occurs in a prison establishment, the Prison Service has arrangements to notify local
         police who act on behalf of the Coroner. When such a death is sudden or unexpected, whether or
         not there are any suspicious circumstances, the following action should be taken:

         (a) The scene must be preserved and the body left in situ;

         (b) The State Pathologist’s Department must always be consulted and given the opportunity to
             attend at the scene and the body should not be moved until a pathologist gives permission;

         (c) Photographs of the scene and of the post mortem examination should always be taken.

         CID will be in charge of the investigation and will follow the instructions on ‘who continues the
         investigation’ as set out in paragraph 16.

9.   MONITORING/REVIEW

     The Chief Inspector, Operational Policy and Support is responsible for reviewing the contents of this
     Service Procedure on an annual basis.


                 Service Procedure No 30/2004

                 Index Entries/

                                    ‘D’ -   Deaths, Suspicious – Police
                                            Investigations into Unexpected,
                                            Unexplained or

                                    ‘P’ -   Police Investigations into Unexpected,
                                            Unexplained or Suspicious Deaths

                                    ‘S’ -   Suspicious Deaths – Unexpected or
                                            Unexplained – Police Investigations into



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