Fatal call - getting away with murder
: a study into influences of decision making at the initial scene of unexpected death

  • Dean Jones

Student thesis: Doctoral Thesis


This thesis examined influences on the decision making process of police officers attending the scenes of sudden and unexpected death in England and Wales. It was initiated following concerns raised by Home Office Registered Forensic Pathologists (HORFPs) in some parts of England and Wales that their services were not being appropriately utilised to assist in the decision as to whether a death was ‘suspicious’ and possibly involving a third party, or a non-suspicious community death. Failure to properly assess the scene of the death can deny the investigation of processes to forensically determine a cause of death, and to lose forensic trace evidence from the body. There were three parts to the research; i) an examination of homicide statistics and forensic post mortem data which showed inconsistency in decision making between some police forces; ii) a case study of 32 real deaths where HORFPs had taken over the conduct of a post mortem procedure where the police had made a decision that the case was not suspicious but where the non-forensic pathologists felt that the case was a suspicious one; and iii) focus groups interviews with key individuals involved in the operational decision making process at the scene of sudden and unexpected death which revealed a lack of training and standardisation in dealing with sudden and unexpected deaths. Overall it was found that homicide cases may be missed due to poor decision making and that this phenomenon is not a new one. The mind-set of police officers dealing with these cases may influence the decision to treat cases as non-suspicious, and thus the services of a HORFP is not utilised to give an expert medical opinion. A major factor appeared to be the vulnerability of the deceased, as well as budgetary pressures. Recommendations are made to address the quality of death investigations, including a national policy, training of front line officers and supervisors and a standard operating procedure.
The wrong decision – a ‘fatal call’ – can lead to a failed investigation and someone ‘getting away with murder’.
Date of Award2016
Original languageEnglish
Awarding Institution
  • University of Portsmouth
SupervisorBecky Milne (Supervisor), Adrian James (Supervisor) & Stephanie Bennett (Supervisor)

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