Oliver Roberts: Prevention of future deaths report

1. Chief Executive Officer of the College of Policing
2. Chair of the National Police Chiefs’ Council  

I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset.      

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013    

On 30th January 2024, I commenced an investigation into the death of Oliver John Roberts, born on the 10th May 1994, who was aged 29 years at the time of his death. The investigation concluded at the end of the Inquest before a jury on the 27th March 2026. The medical cause of death was:
Ia Hanging

The conclusion of the jury was a narrative conclusion – Oliver John Roberts died as a consequence of self-suspension by ligature, where his intention remains unclear. Oliver’s death was contributed to by failure to determine appropriate level of risk.   

On the 28th January 2024 Ollie was found suspended by a ligature in a wooded area in [REDCATED], Bournemouth, Dorset. At around 13.48 hours on the 27th January 2024, Derbyshire Police reported to Dorset Police that Ollie’s estranged wife had contacted them to advise he had sent a photograph of a ligature and then facetimed her with the ligature around his neck. He had a history of making threats to end his life and information provided to the police was that he was making threats for sympathy from his estranged wife to rekindle the relationship.   Information was also obtained that he had called his son that day at 13.15 hours to say he would not see him again.     Ollie was treated as a missing person by Dorset Police and was graded as medium risk when the initial missing person risk assessment was undertaken by the Force Incident Manager at 16.00 hours on 27th January 2024. Following a review recorded by an Inspector at 23.05 hours, Ollie was graded as a high risk missing person. A Grade 2 application for communications data was sent to the communication data investigation team at 12.32 hours on the 28th January 2024 which led to data being provided to Dorset Police, which led to Ollie being found deceased at approximately 14.40 hours that day. Evidence obtained after his death revealed Ollie was last known to be alive at 19.39 hours. 

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.  

(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.  
(2) Communications data can be obtained by Police forces in England and Wales  pursuant  to  the  Investigatory  Powers Act  2016  (the Act).  In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.  
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.  
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of  investigation  into  a  serious  crime  and  early  disclosure  by  the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime. 
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no   practical   guidance,   such   as  Authorised   Professional   Practice Guidance,  to  assist  Forces  and  their  officers,  as  to  how  and  when applications should be made and authorisations should be given.  
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is  a  lack  of  guidance  to  police  officers  nationally  as  to  what  would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.  
(7) I am concerned that the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016.   

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by 25th May 2026.   I, the coroner, may extend the period.    Your response must contain details of action taken or proposed to be taken,  setting out the timetable for action. Otherwise, you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 
(1) Ollie’s family
(2) Chief Constable of Dorset Police
(3) Chief Constable of Devon and Cornwall Police
(4) Dorset Healthcare University NHS Foundation Trust

I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.         

[REDACTED]  

Rachael C Griffin HM Senior Coroner for Dorset 30th March 2026