Angiolini Inquiry

The Angiolini Inquiry

Date	2021 (2021) – (in progress)
Location	London, United Kingdom
Participants	Rt. Hon. Lady Elish Angiolini KC (Chairwoman)
Website	www.angiolini.independent-inquiry.uk

On 22 November 2021, Lady Elish Angiolini KC was commissioned by then Home Secretary, Priti Patel, to conduct an independent inquiry as to how off-duty Metropolitan Police officer, Wayne Couzens, had the ability to kidnap, rape, and murder Sarah Everard, a member of the public. One aim of the inquiry was to ensure Everard's family, as well as the public, received a full explanation as to the causes and factors contributing to her murder.

Another aim was to 'bring about greater and earlier recognition of potential sexual and murderous predators, and thereby help improve the safety of women in public spaces'.

Background

Main article: Murder of Sarah Everard

On the evening of 3 March 2021, 33-year-old Sarah Everard was kidnapped in South London, England by off-duty Metropolitan Police constable Wayne Couzens. Couzens identified himself as a police officer, handcuffing Everard, and placing her in his car, before driving her to a location near Dover where he raped and strangled her, before burning her body and disposing of her remains in a nearby pond.

Inquiry

Setting up of the Inquiry

Following Couzens' sentence to a whole life order on 30 September 2021, on 22 November 2021, Patel announced to Parliament that an independent inquiry was being launched under the management of Lady Angiolini. Patel stated that the inquiry would be over two parts, with the first establishing how Couzens "was able to serve as a police officer for so long and seek to establish definitive account of his conduct", as well as seeking to understanding "the extent to which his behaviour rang alarm bells with his colleagues."

Lady Elish Angiolini KC

With the Angiolini Inquiry being designated as a non-statutory inquiry, it meant Everard's family could be given "closure as quickly as possible", with a statutory inquiry's recommendations not being made for a "number of years".

The inquiry interviewed 144 witnesses, which included current and former police officers and staff, as well as other relevant organisations and members of the public.

Part 1

On 10 January 2022, the terms of reference for Part 1 of the inquiry were set as to 'establish a comprehensive account of the career and overall conduct of the killer of Sarah Everard, to identify any missed opportunities, and to make recommendations based on the findings.'

Patel was asked to conclude the first part of the inquiry within nine months from when the terms of reference were set. Whilst work started immediately, there were some delays, due to Couzens, at that time, facing ongoing legal and misconduct proceedings, limiting some aspects of the inquiry proceeding.

The aim of the first part of the inquiry was to 'establish a definitive account of the career and conduct' of Couzens. The report also looked at the years before the incident, establishing a timeline ending at the point where he kidnapped, raped and murdered Everard.

On 29 February 2024, the first part of the Angiolini Inquiry was published. Home Secretary James Cleverly made a statement in the House of Commons in response to the report's publication.

Timeline of career

Month	Year	Event	Organisation
December	2006	Joins Kent Police as a Special Constable (SC)	Kent Police
May	2008	Submits application to join Kent Police as a regular officer. Application fails at financial vetting stage (having entered into an Individual Voluntary Arrangement in February 2007, due to financial difficulties)
		Applies and is interviewed for promotion to the equivalent rank of sergeant in the Special Constabulary (known as 'section officer'). Successful at interview and is promoted
October	2009	Submits application to join the Civil Nuclear Constabulary. Passes the recruitment vetting checks and the fitness test (on the second attempt)
September	2010	Resigns from Kent Police Special Constabulary
March	2011	Appointed to full-time role as a Police Constable (PC) with the Civil Nuclear Constabulary	Civil Nuclear Constabulary
June		Granted National Security Vetting clearance at the level of Developed Vetting
July		Posted as an authorised firearms officer (AFO) at Sellafield, Cumbria
Early (unknown month)	2012	Applies for and is granted voluntary transfer to Dungeness, Kent
March	2013	Successfully completes two-year probation
Unknown		Studies for sergeant's exam, intending to take this in 2014
Unknown		Applies to join Kent Police, with his application rejected at the shortlisting stage
January	2014	Applies to and is successful in joining the Strategic Escort Group
July		Deployed to the Strategic Escort Group, where he later claims to several people he has been deployed overseas, with this being a lie
Mid (unknown month)	2016	Looks for opportunities to move on from the Civil Nuclear Constabulary
September		Returns to substantive post at Dungeness, Kent
June		Starts another application to join Kent Police, but doesn't submit this
February	2017	Submits another application to join Kent Police, but withdraws this a few months later
May	2018	Applies to join the Metropolitan Police. He later tells them he would "prefer not to transfer" as an AFO, wanting to be considered for frontline policing on response or to qualify as a detective
September		Couzens leaves the Civil Nuclear Constabulary, with his application to join the Metropolitan Police being successful
		Assigned to Bromley Basic Command Unit, where his vetting level, since downgraded, is transferred across	Metropolitan Police
November		Having almost finished a course for rejoiners and transferees, he is told he would need to undergo a full 18-week foundation course for new recruits as well as a two-year probationary period
February	2019	Having completed training, he is deployed to Bromley Emergency Response on Team B
Late February		Submits application to transfer to the Parliamentary and Diplomatic Protection Command. His first application is unsuccessful
June		Submits a further application to transfer to the Parliamentary and Diplomatic Protection Command, where he passes an interview, risk assessment process and training courses
February	2020	Posted to the Parliamentary and Diplomatic Protection Command at Lillie Road Base
March		Having only been in his role with the Parliamentary and Diplomatic Protection Command for a month, he submits an application to rejoin the Civil Nuclear Constabulary. Despite reaching and passing the interview stage, he withdraws his application
July		Having been with the Parliamentary and Diplomatic Protection Command for approximately five months, he is signed off work for three weeks, due to sustaining an injury to his left index finger. He told the Metropolitan Police this was from an accident from a drill whilst completing DIY (it would later emerge this was a purposeful action to self-harm)
August		He is assessed and deemed fit for 'recuperative duties', consisting of office-based work, mainly from home, in the Counter Terrorism Protect and Prepare Unit
Mid October to late November		Receives virtual physiotherapy from the Police Rehabilitation Centre
December		Discharged from Occupational Health having passed a medical functionality test
January	2021	Passes the job-related fitness test on the second attempt
February		Completes necessary firearms and TASER re-training. During requalifying, he works with officers on COVID-19 patrols, enforcing the Regulations in force at the time
Mid-February		Firearms authority is reinstated and he resumes duties as an AFO based at Lillie Road
2 March		Completes what will be his last shift with the Parliamentary and Diplomatic Protection Command, posted to guard a protected site
16 July		Dismissed without notice for gross misconduct after admitting the kidnap and murder of Everard

Timeline of Couzens' offending

Month	Year	Offence (potential related legislation)	Details	Charge/Sentence
Unspecified date(s)	Between 1992 and 1997	Statutory rape (Sexual Offences Act 1956)	Couzens allegedly sexually assaulted a child. This may have been in relation to his alleged relationship with a 14-year-old when he was 23-years-old (the Angiolini Inquiry mentions that 'due to her being too young to consent, any sexual activity with the victim would have been a crime. The alleged sexual assault was, and remains today, serious sexual offending whether compared with the Sexual Offences Act 1956 in force at the time or the law that applies today'). The allegation wasn't reported at the time.	Not subject to a police investigation
Unspecified date(s)	1995	Unspecified motoring offence	In his early twenties, Couzens declared on application forms he had been found guilty of a driving offence in 1995.	Guilty. Sentence unknown
		Attempted Kidnapping (Criminal Attempts Act 1981)	A woman reported an unidentified man had attempted to kidnap her at knifepoint in North London. Following his arrest for the offences related to Everard, the woman contacted the police, stating she recognised him from photos in the media as the man who had attempted to kidnap her. Couzens was arrested and questioned in relation to this offence in March 2022.	No further action due to "evidential difficulties"
Early Spring	2003	Unknown	Whilst in the Territorial Army, a woman alleged that he acted in an 'intimidating manner' towards her during an event. This included him blocking her path and demanding her for her telephone number. She didn't report this to police at the time, however, identified Couzens after his photo was published following his arrest. She stated how Couzens was "intimidating", making her feel "deeply uncomfortable." She didn't wish to provide a statement to make a complaint.	No further action due to victim not making a complaint
Unspecified date(s)	2004	Possession of extreme pornography (Obscene Publications Act 1857 (the offence occurred before the more modern legislation regarding extreme pornography within Section 63 of the Criminal Justice and Immigration Act 2008))	Whilst socialising with a group of reservists, Couzens is alleged to have shown pornographic videos, showing violent and extreme sex acts, including bestiality. On his arrest for the offences in connection with Everard, this was reported to the Metropolitan Police, whereby Couzens was arrested in relation to possession the extreme pornography in March 2022.	No further action due to "evidential difficulties"
Summer		Indecent exposure (s66 Sexual Offences Act 2003)	Whilst in South London, Couzens allegedly exposed himself to a teenage girl, masturbating whilst driving. She did not report this at the time, but later recognised Couzens in media related to his involvement in Everard's kidnap, rape and murder, reporting this to the Metropolitan Police in late 2021. Couzens was arrested and interviewed in relation to the allegation in March 2022.	No further action due to insufficient evidence
Late 2006 to early 2007		Attempted rape (Criminal Attempts Act 1981)	During an event in London, it was alleged that Couzens attempted to rape a woman. She did not report this at the time, but contacted the Metropolitan Police after believing she recognised him as the suspect from images of him in the media in relation to his involvement in Everard's case and he was arrested and interviewed in relation to the allegation in March 2022.
July	2007	Theft (s1 Theft Act 1968)	Having left the Territorial Army, Couzens failed to return equipment and uniform, being charged £526 as a result. Couzens did not pay the charge or return the equipment and uniform.	No criminal investigation launched
Between May 2008 and September 2010		Sexual harassment (s26 Equality Act 2010)	Couzens allegedly left six photographs on a young woman's phone, showing his semi-erect and erect penis. He was confronted about this but "laughed it off and said it was nothing". This incident was not reported at the time or after his arrest and conviction in relation to offences he committed against Everard.
		Sexual assault (s3 Sexual Offences Act 2003)	Whilst applying a plaster to a young woman's leg, Couzens allegedly made her feel "extremely uncomfortable" when he lifted her skirt higher than required, proceeding to "very slightly" squeeze her knee.This incident was not reported at the time or after his arrest and conviction in relation to offences he committed against Everard.
		Sexual assault (s3 Sexual Offences Act 2003)	Whilst in a car home from a social event, Couzens allegedly put his hand underneath a woman's dress, touching her over her underwear. This incident was not reported at the time or after his arrest and conviction in relation to offences he committed against Everard.
21 November	2008	Indecent exposure (s66 Sexual Offences Act 2003)	Couzens allegedly exposed himself, masturbating in front of a woman whilst he was on foot in South London. The victim reported this incident on the same day. Officers attended the scene and despite not taking a statement, recorded the crime, with no suspect identified. After Couzens' arrest for offences against Everard, the victim of the indecent exposure approached police stating she believed Couzens was the suspect. Couzens was arrested and interviewed in relation to the allegation in March 2022.	No further action due to insufficient evidence
2008		Indecent exposure (s66 Sexual Offences Act 2003)	Couzens allegedly exposed himself to Magic FM DJ Emma Wilson, known as Emma B, as she walked past an alleyway in Greenwich, south-east London. Wilson reported this to police, but alleged how officers laughed at her when she did so. When Couzens photo was published in news reports related to his involvement in offences against Everard, Wilson recognised him, with the Metropolitan Police re-investigating her complaint.	Unknown
2013		Unspecified motoring offence	Couzens commits two motoring offences on two separate occasions in 2013 and 2014. Specific details are unknown.	Unknown
2014
9 June	2015	Indecent exposure (s66 Sexual Offences Act 2003)	Couzens allegedly exposed his erect penis whilst driving a car in Dover town centre. The incident was reported the same day to Kent Police, with Couzens being identified as the registered keeper of the involved vehicle. However, the investigation did not progress, with Couzens not being questioned regarding the report. After his arrest for the abduction, rape and murder of Everard, the case was reopened and he was charged with indecent exposure in September 2022. In February 2023, he entered a not guilty plea to the offence.	Court accepting the request of the prosecution for the offence to 'lie on the file'
Between March and October	2019	Sending grossly offensive messages on a public communications network (s1 Communications Act 2003)	After his arrest for the kidnap, rape and murder of Everard, material within a WhatsApp group that Couzens and other officers in the Metropolitan Police were in emerged. Inappropriate and grossly offensive messages were sent by Couzens, including making obscene sexual and mocking comments about domestic abuse victims, as well as comments that discriminated about people's race and ethnicity.	Not investigated due to criminal proceedings occurring in relation to offences against Everard
Summer		Sexual assault (s3 Sexual Offences Act 2003)	Couzens allegedly sexually assaulted a man who was in drag at a Kent bar, touching him inappropriately. This led to a confrontation where Couzens told the victim he was a police officer. He invited the victim outside to perform a sex act. This incident was reported after Couzens was arrested in relation to offences in connection with Everard.	Unknown
October		Rape (s1 Sexual Offences Act 2003)	Couzens allegedly raped a woman under a bridge in London. This was reported to police in March 2020, however, the investigation was closed due to a suspect not being identified. In April 2021, the victim recontacted police having seen Couzens image on the news in relation to his involvement in Everard's case and identified him as her attacker. Couzens was arrested and interviewed in relation to the report in March 2022.	No further action due to "evidential difficulties"
13 November	2020	Indecent exposure (s66 Sexual Offences Act 2003)	Couzens exposed himself to a female cyclist, masturbating while standing next to woodland on a country lane in Ringwould, Kent near to his address. The same day, she reported this to police, but the investigation closed after no suspect was identified. Later, the victim contacted police, identifying a photo of Couzens in the media after his arrest for offences related to Everard, as the suspect who had exposed himself. Couzens was interviewed and police explained this to him, however, he provided 'no comment' to questions. He was charged with indecent exposure in August 2022.	Pleaded guilty, sentenced to 19-months-imprisonment in March 2023
4 December		Sending grossly offensive messages on a public communications network (s1 Communications Act 2003)	Whilst working from home when an officer with the Metropolitan Police, Couzens allegedly sent an unsolicited photo to an online clothing vendor of his erect penis. This incident was not reported to police.	No investigation due to no report being made
3 February	2021	Indecent exposure (s66 Sexual Offences Act 2003)	Couzens allegedly indecently exposed his erect penis whilst on foot in Kent. The victim reported the incident the same day, however, as a suspect wasn't identified, the investigation was closed on the same day. After Couzens arrest for the kidnap, rape and murder of Everard, the investigation was reopened. He was arrested and questioned in relation to the report in March 2022.	No further action due to the alleged offence not meeting the evidential threshold for charging
Between 22 January and 1 February		Indecent exposure (s66 Sexual Offences Act 2003)	Couzens allegedly indecently exposed himself on two separate occasions in Kent, whilst at a drive-through of a restaurant. Information about these offences emerged after Couzens was investigated for two other reports of indecent exposures in mid to late February 2021 in Kent.	Pleaded not guilty to both charges, with the alleged offences ordered to 'lie on the file'
Between 30 January and 6 February
14 February		Indecent exposure (s66 Sexual Offences Act 2003)	Couzens indecently exposed himself on two separate occasions at a drive-through of a McDonald's restaurant in Swanley, Kent. One of the victims at the restaurant described how Couzens had exposed his erect penis to her as she turned around to hand him food he had ordered at the window of the drive-through. She described how she burst into tears. Later that month, the incidents were reported and Couzens was identified as a suspect, with Couzens having used his bank card and driving his own car at the time of the offence. However, no further action was taken relating to investigating the incidents until after Couzens was arrested for the abduction, rape and murder of Everard. Having been interviewed in prison, Couzens was charged with the offences in March 2022.	Pleaded guilty and was sentenced to six-months-imprisonment for both incidents in March 2023
27 February
March		Kidnap (Common Law) Rape (s1 Sexual Offences Act 2003) Murder (Common Law)	On the evening of 3 March 2021, Everard was kidnapped in South London, England. Couzens identified himself as a police officer, handcuffing her, and placed her in his car before driving her to near Dover where he raped and strangled her, before burning her body and disposing of her remains in a nearby pond.	On 30 September, Couzens was sentenced to life imprisonment with a tariff of a whole life order, with Lord Justice Fulford justifying the severity of the punishment by saying that Couzens's use of his position as a police officer to detain Everard was the "vital factor which in my view makes the seriousness of this case exceptionally high".
2022		Possession of indecent images of children (s52A Criminal Justice Act 1988)	Couzens' electronic devices were seized when he was arrested for offences related to Everard. In 2022, a final review of material on the devices located 19 indecent images on his devices. In a prepared statement during an interview at HM Prison Belmarsh, Couzens provided a prepared statement, denying having ever downloaded or viewed indecent images of children.	No charges due to insufficient evidence

Recommendations

Part 1 of the inquiry provided the following recommendations:

No.	Overview	Details	Involved parties	Due date
1	Approach to investigating indecent exposure	At the earliest opportunity, and by September 2024 at the latest, police forces should ensure that they have a specialist policy on investigating all sexual offences, including so-called ‘non-contact’ offences, such as indecent exposure.	All police forces	Earliest opportunity (by September 2024)
2	Guidance and training on indecent exposure	By December 2024, the College of Policing, in collaboration with the National Police Chiefs’ Council, should improve guidance and training on indecent exposure, in order to improve the quality of investigations and management of indecent exposure cases. In particular, the College of Policing should: - review and update training, informed by crime statistics and research into the nature of indecent exposure and its impact on victims; - review and update the guidance for police officers to improve the handling of indecent exposure cases; - include guidance on appropriate resourcing for investigations; and - ensure that guidance and training reflect the Sentencing Council guidelines, which recognise factors indicating increased harm and culpability. This activity should be informed by the results of Recommendation 4 below	College of Policing National Police Chiefs' Council	December 2024
3	Treatment of masturbatory indecent exposure within the criminal justice system	With immediate effect, the Home Office, Ministry of Justice, College of Policing and National Police Chiefs’ Council should work together to conduct a fundamental review of the way masturbatory indecent exposure is treated within the criminal justice system. The review should focus on: recognising the seriousness of the offence; identifying it as an indicator of disinhibition by perpetrators; and understanding and addressing the wider issue of sexual precursor conduct so as to prevent victimisation, improve the response to victims when it occurs and bring more offenders to justice.	Home Office Ministry of Justice College of Policing National Police Chiefs' Council	Immediate effect
4	Research into masturbatory indecent exposure	With immediate effect, the Home Office, in collaboration with the College of Policing, should commission research to establish if there is an evidence-based link between active masturbatory indecent exposure and subsequent contact offending. Where relevant, findings should then be used to shape policy, training and guidance for police officers investigating indecent exposure cases (as per Recommendation 2).	Home Office College of Policing	Immediate effect
5	Public information campaign on indecent exposure	By March 2025, the Home Office, together with the National Police Chiefs’ Council, should launch a public campaign to: - raise awareness about the illegality/criminality and legal consequences of any type of indecent exposure and boost the confidence of victims to report cases of indecent exposure to ensure that more offenders are brought to justice; and - increase publicity around the relevant legislation in order to encourage reporting of unsolicited photographs sent of genitals with the intention to cause harm, distress or humiliation and to discourage perpetrators from doing so.	Home Office National Police Chiefs' Council	March 2025
6	Review of indecent exposure allegations and other sexual offences recorded against serving police officers	By September 2024, the National Police Chiefs’ Council, in collaboration with all force vetting units, and building on the results of the recent data-washing exercise, should conduct a review of the circumstances of all allegations of indecent exposure and other sexual offences recorded on the Police National Database and the Police National Computer against serving officers. This is to identify, investigate and ultimately remove those officers found to have committed sexual offences from all police forces.	National Police Chiefs' Council Individual police force vetting units	September 2024
7	In-person interviews and home visits	With immediate effect, the College of Policing, in collaboration with force recruitment, should ensure that every new candidate applying to become a police officer in any police force undergoes an in-person interview and home visit. This should be designed to provide a holistic picture of the candidate and a better understanding of the candidate's motivations for joining the police and their dedication to serving the public. In particular, this should include the following: - An in-person interview with the candidate to ensure that face-to-face contact is made with the recruiting force before the vetting or onboarding of the candidate is progressed. - A visit to the residence of all new candidates. This should be used as another opportunity, in advance of vetting enquiries, to engage with the candidate, relevant family members or other occupants of the residence, wherever possible. - An integrity questionnaire, used as part of the in-person home visit, to explore fully the candidate's personal attitudes and values, including increased scrutiny of the candidate's motivations and suitability for joining the police. - Corresponding guidance and training for home visits must be developed to ensure that the visits will enable a better sense of the candidate's character, rather than judge living arrangements or socio-economic status.	College of Policing All police force's recruitment teams	Immediate effect
8	Recruitment and vetting policy, processes and practices	By June 2024, the College of Policing, in collaboration with force vetting units, should take further steps to prevent those unsuitable for policing from joining the policing profession. This should include further developing the Vetting Code of Practice, Authorised Professional Practice on Vetting, and other guidance on recruitment and vetting practices in order to prevent those who commit sexually motivated crimes against women and those otherwise unsuitable for policing from holding the office of constable. In particular, recruitment and vetting policy, processes and practices must be developed in the following areas: - Applicants should be required to undergo an assessment of their psychological suitability for the role (which is not just a questionnaire). - There should be more robust use of the Police National Database during vetting, including as a tool to reveal unreported adverse information about applicants to ensure that potential risks are not missed. In particular, the Database should be used when individuals attempt to move between forces. - Any individual identified as having a conviction or caution for a sexual offence should be rejected during police vetting. This should be clearly outlined in the Vetting Code of Practice and reflected in the Authorised Professional Practice on Vetting, which should consider all contact and non-contact sexual offences. - The Authorised Professional Practice on Vetting should be amended to make it clear that military and/or Ministry of Defence checks should be carried out on all applicants who have served as military reservists. - There should be a fundamental review of the link between debt, mental health, vulnerability to corruption and suitability to be a police officer, to inform vetting decisions. Detailed consideration should be given to the amount of unsecured personal debt held by officers, and rules should be amended to mandate officers to report any significant changes in debt to vetting teams. In addition, the rules should require applicants and officers to provide further insight into their finances, including any payday loans, when requested during the vetting process. - There should be increased rigour in relation to checks for authorised firearms officers, to ensure that vetting standards are met, as well as the introduction of a psychological assessment and an appropriate process for seeking feedback from supervisors or line managers to determine suitability for the role. - No police officer should be onboarded, even if only for initial training, before all vetting is complete. In addition, each officer's force vetting should be completed before their National Security Vetting is initiated. All force vetting information should be passed to National Security Vetting officers for consideration.	College of Policing Individual police force's vetting units	June 2024
9	Professional rigour in decision-making	By March 2025, the College of Policing, in collaboration with force vetting units, should take steps to improve the quality and consistency of police vetting decision-making. This should include encouraging the use of greater professional rigour and curiosity when investigating lines of enquiry, in order to prevent those who commit sexually motivated crimes against women and those otherwise unsuitable for policing from joining the policing profession. These steps should include the following: - Recruiting forces should be able to request that unresolved allegations discovered during vetting processes be reinvestigated. - In collaboration with the National Police Chiefs’ Council, a national vetting capability should be created, as an advisory function, to provide another layer of confidence in instances where complex vetting investigations and decisions are required. In such cases, forces should approach the national vetting function to seek proposed lines of enquiry and ensure that they are following an agreed, standardised approach when considering complex cases. - Consideration should be given during vetting to any information or intelligence about police officers being reported missing, regardless of how quickly such reports were closed. - Forces must ensure that force vetting units are complying with and practising Section 6.2 of the College of Policing Authorised Professional Practice on Vetting (2021), which states that force vetting units “must record the results of vetting enquiries; the rationale for refusing, suspending, withdrawing or granting clearance, including with restrictions; and where adverse information has been revealed and considered”. This is to ensure that an audit trail is recorded to give the force confidence in decisions made at the time and to allow future vetting officers to constructively scrutinise vetting enquiries and outcomes.	College of Policing Individual police force's vetting units National Police Chiefs' Council	March 2025
10	Vetting Code of Practice and transfers	With immediate effect, all recruiting forces should have regard to the new Vetting Code of Practice, which requires the parent force to provide all relevant information requested about the transferee to enable an effective assessment of risk by the force conducting a full re-vet of the transferee.	Individual police force's recruitment teams	Immediate effect
11	Information-sharing	By December 2024, the College of Policing, in collaboration with force vetting and recruitment units, should ensure that information-sharing practices, including data retention policies, are strengthened in order to prevent those who commit sexually motivated crimes against women and those otherwise unsuitable for policing from remaining in, or moving across, the policing profession. In particular, there should be a focus on the following information: - Previous failures to achieve vetting should be recorded by all forces and flagged to recruiting forces. This should also trigger a re-vet with the current or recruiting force. - A shared agreement should be made about the quality, relevant and necessary content, and sources of information that will be provided in a reference for a future force, also known as a ‘shared referencing protocol’, with directed questions that must be answered (for example, regarding any past disciplinary or honesty/integrity issues). Information to be shared as part of the protocol should be covered within the relevant forces’ fair processing notices. The protocol should apply to all transfers and applications to police forces from individuals in the uniformed services, including: • the Ministry of Defence (including the Army, the Royal Air Force and the Royal Navy, as well as their respective reserve forces); • fire and rescue services; • HM Prison and Probation Service; • other police forces; and • relevant government agencies, such as Border Force or Immigration Enforcement. This is to improve forces’ access to – and ability to use – the totality of information they hold about officers in order to prevent, detect and deal with those likely to commit offences. - As per Recommendation 8(b), there should be expanded access to and use of the Police National Database, including as a tool for revealing relevant uninvestigated adverse information about officers. d. Any adverse information or intelligence (developed or otherwise) should be passed by the current Professional Standards Directorate to the receiving Professional Standards Directorate for any officers transferring. No decisions on their appointment should be made until that intelligence has been reviewed, recorded and closed and the vetting units have had time to consider it. If the recruiting force identifies adverse information as a result of the vetting process, this should be shared with the current force for consideration and potential action.	College of Policing Individual police force's vetting units Individual police force's recruitment team	December 2024
12	Right to privacy	With immediate effect, police forces should convey to all existing and prospective officers and staff that they must be held to a higher standard of behaviour and accountability than members of the public, and that therefore their right to privacy can be fettered in certain circumstances. These circumstances include, but are not limited to: recruitment, vetting, aftercare, transfer, promotion, role change, returning to policing and maintaining standards. This is to ensure that members of the police are fully aware and accountable for the unique powers entrusted to them and the standards of professional behaviour they swear to uphold. Updated fair processing notices concerning changes to processing of personal data should be provided prior to any new processing taking place, including data-sharing.	Individual police forces	Immediate effect
13	Aftercare	By December 2024, the College of Policing, in collaboration with all force vetting units, should develop a stronger approach to force vetting aftercare in order to monitor an individual effectively throughout their career with the police and be aware of any change in circumstances as soon as possible to ensure that potential risks/red flags are identified and assessed. In particular, that approach should include the following: - Mandatory, randomised re-vetting should be introduced, as an additional layer to standardised vetting periods, for police officers and staff, akin to randomised drug-testing. - In addition to police officers and staff being required to declare any material changes in their circumstances within a managed system, such as a human resources system, supervisors, or anyone with concerns relating to behaviour, welfare or performance, should report them to Professional Standards Departments at any point. - Professional Standards Departments should systematically exchange relevant and necessary information with vetting and counter-corruption units to consider information disclosed by any individual, and any action necessary.	College of Policing Individual police force's vetting units	December 2024
14	Positive culture and elimination of misconduct or criminality often excused as ‘banter’	With immediate effect, every police force should commit publicly to being an antisexist, anti-misogynistic, anti-racist organisation in order to address, understand and eradicate sexism, racism and misogyny, contributing to a wider positive culture to remove all forms of discrimination from the profession. This includes properly addressing – and taking steps to root out – so-called ‘banter’ that often veils or excuses malign or toxic behaviour in police ranks.	Individual police forces	Immediate effect
15	Reporting by police officers and staff of harassment, sexual offences and inappropriate behaviour committed by fellow officers	With immediate effect, all police forces should take action to understand and confront the barriers that police officers and staff face when reporting sexual offences committed by a person that they work with or in the workplace. This is in order to encourage victims, who are also police officers or police staff, to come forward and submit complaints, as well as to identify and remove those who are not fit for service. To do this, forces should: - ensure, when a complaint is made, that sufficient and appropriate resources are dedicated to supporting the complainant, including maintaining anonymity where needed or requested, and ensuring an investigation is carried out as appropriate; - address cultural barriers to reporting, such as re-victimising complainants by labelling or treating them as ‘troublemakers’; and - provide dedicated reporting processes for women in police forces who experience inappropriate behaviour related to their gender.	Individual police forces	Immediate effect
16	Recruitment and retention of women in police forces	By September 2024, the College of Policing and the National Police Chiefs’ Council should review and examine the conditions of female officers and staff in order to encourage more women to join the police and progress in policing careers. To ensure success, this should include a review of: a. working conditions that do not address the realities of modern working lives, including families where both parents are officers and share caring responsibilities; b. processes, training and refreshers for officers returning from parental leave; and c. kit, equipment and facilities designed largely by and for men.	College of Policing National Police Chiefs' Council	September 2024

Conclusions

No.	Details
1	Wayne Couzens deliberately targeted his victims and, in some cases, his behaviour made them question their own responsibility for what happened, deterring them from reporting his behaviour to an appropriate authority.
2	An increase in the frequency of sexual offending can be deadly serious and needs to be treated as such.
3	There was a lamentable and repeated failure to deal, in a reasonable and professional manner, with the several allegations reported to different police forces by a number of people prior to Sarah Everard's murder.
4	The actions of the investigating officer in the June 2015 case [Couzens exposing himself] fell far short of what would be expected of a competent police constable.
5	The officer in the June 2015 case placed far too little emphasis on the quality of the information provided by the informant.
6	The officer in the June 2015 case gave too much weight to untested and subjective opinions about the informant's reliability, as well as to a possible mistake the informant may have made in describing a feature of the incident.
7	The failure to investigate the June 2015 indecent exposure report was a red flag and a missed opportunity to disrupt or prevent Wayne Couzens’ offending and allowed him to continue working as a police officer.
8	The officer in the case for the 2021 drive-through indecent exposure offences also placed too little emphasis on the quality of the information provided by the informant.
9	Rather than providing an excuse for inaction, unanswered questions about a case should spur an investigator to look for further evidence to prove the matter either way.
10	The investigation of the 2021 drive-through offences was poor and slow, demonstrating a complete lack of investigative curiosity.
11	It is unlikely that Wayne Couzens’ crimes against Sarah Everard could have been disrupted following the report of the drive-through offences on 28 February 2021.
12	The three lethargic and inadequate investigations into the allegations of indecent exposure against Wayne Couzens suggest the officers in the cases found reasons not to pursue the criminal investigation rather than build a successful case for prosecution.
13	The term ‘flashing’, used in the now obsolete College of Policing guidance, conveyed nothing of the victim's experience and may have downplayed the seriousness of the offender's behaviour.
14	The example of indecent exposure used in the now obsolete College of Policing guidance is inadequate. This example has informed a whole national cohort of officers who are currently responsible for investigating indecent exposure cases.
15	The Inquiry is extremely concerned that current national guidance for police forces on investigating sexual offences does not appear to cover indecent exposure, which may support a view that indecent exposure is not a serious offence.
16	It is inappropriate and unethical that any victim of crime should be further victimised by being the recipient of unwanted attention from reporters following court proceedings.
17	The Inquiry has serious concerns about treating indecent exposure as a low-level offence within policing.
18	Reported cases of indecent exposure must be thoroughly and comprehensively investigated. Victims also need to be encouraged to report.
19	The purchases of garments made by Wayne Couzens via an online marketplace were sexually motivated and intended for the purpose of his sexual gratification [on at least 11 occasions, Couzens requested female sellers to 'cum' into the items, negotiating increased prices for them to do so].
20	Evidence seen by the Inquiry that Wayne Couzens allegedly sent an unsolicited photograph of his erect penis to an online seller provides further potential evidence of his willingness to indecently expose himself.
21	The evidence of a historical allegation of very serious sexual assault suggests that Wayne Couzens’ offending in 2021 was not an isolated incident but may have been part of a pattern of offending dating back many years.
22	Wayne Couzens being reported as a missing person in 2013 was a red flag about his suitability to be a police officer.
23	Wayne Couzens, at times, sought to deliberately mask his financial situation to increase his chances of being recruited to various police forces. There were additional failings on the part of some of those involved in his recruitment and vetting.
24	Home visits are an important part of the application process and should be used for all police recruitment.
25	At Kent Police, the same vetting policy appears to have been applied in different years by different teams with different results. There was also an element of discretion exercised by the force vetting staff even where the guidance itself was quite prescriptive.
26	Wayne Couzens remained a special constable with Kent Police despite having failed vetting to be a regular officer in the same force.
27	Wayne Couzens did not provide Thames Valley Police with all of the financial information requested by them for his force vetting for the Civil Nuclear Constabulary.
28	Red flags about Wayne Couzens’ history of financial difficulties and that he was a Russian speaker were not given proper consideration when he applied to join the Civil Nuclear Constabulary.
29	Thames Valley Police made the correct recommendation to the Civil Nuclear Constabulary, namely that Wayne Couzens should be refused force vetting clearance because he appeared to have a current Individual Voluntary Arrangement where a portion of his debt had been written off. However, the rationale given for the recommendation suggested that the Thames Valley Police Central Vetting Unit may not have properly understood the relevant guidance.
30	The Civil Nuclear Constabulary's decision to put Wayne Couzens forward for National Security Vetting before receiving a recommendation about his force vetting clearance enabled him to evade proper scrutiny of his finances through the lens of police force vetting.
31	The Civil Nuclear Constabulary made its decision to grant force vetting clearance to Wayne Couzens on the basis of limited and incomplete information and consequently missed red flags.
32	Owing to a principle of vetting confidentiality, the Civil Nuclear Constabulary did not have sight of the material generated by the National Security Vetting process when deciding to employ Wayne Couzens.
33	The Inquiry is satisfied that, when the Civil Nuclear Constabulary put Wayne Couzens forward, via the Office for Civil Nuclear Security, for Developed Vetting clearance, both organisations were aware that there were some financial issues in his background.
34	The Office for Civil Nuclear Security made the decision to grant Wayne Couzens Developed Vetting clearance without considering the available information from police vetting, including the recommendation from Thames Valley Police that he should be refused force vetting clearance.
35	The potential risks identified at the time Wayne Couzens was undergoing National Security Vetting related to his finances.
36	The Civil Nuclear Constabulary used the National Security Vetting process inappropriately as part of a wider assessment of Wayne Couzens’ suitability to carry a firearm.
37	The Civil Nuclear Constabulary downgraded Wayne Couzens’ National Security Vetting clearance level in 2017 but re-vetting was not required. At that time the Civil Nuclear Constabulary remained unsighted on the Police National Database entry in relation to the 2015 allegation of indecent exposure.
38	Even if a full National Security Vetting renewal had been undertaken, it is unlikely that the 2015 allegation would have surfaced because, while United Kingdom Security Vetting had access to the Police National Computer (which contains information about recorded criminality), it did not have access to the Police National Database (which contains intelligence about an individual). This is a significant gap.
39	The Metropolitan Police Service conflated two separate disclosures relating to his debt when reconsidering, after his arrest for the abduction, rape and murder of Sarah Everard, Wayne Couzens’ vetting process for the Civil Nuclear Constabulary. This meant that the vetting review report incorrectly narrated the extent of Wayne Couzens’ debt and financial difficulties.
40	The Inquiry found a lack of attention to detail in the Metropolitan Police Service’s internal review report.
41	The Inquiry questions why the Metropolitan Police Service vetting officer did not ask the Civil Nuclear Constabulary about the unintentional TASER discharge incident.
42	Due to the passage of time, the Metropolitan Police Service cannot now confirm whether the intelligence about the 2015 indecent exposure allegation involving Wayne Couzens was not identified because the correct checks were not carried out, or was identified but not considered during his original vetting in 2018.
43	The Police National Database entry about the 2015 indecent exposure allegation was considered and discounted by the senior vetting officer, who indicated that vetting clearance would still have been recommended. The Inquiry has not seen the tasking instructions to the senior vetting officer to clarify what was required in the retrospective assessment, but the recorded rationale for how the Police National Database entry had been considered during the re-vet process did not include any explanation of why the information had been discounted. This is a deeply significant failing.
44	Recruiting forces are at risk if previous allegations of crime involving prospective transferees are not properly investigated at the time and incomplete information is therefore potentially provided to the employing force.
45	In cases where allegations are made but not investigated properly, vetting officers cannot commission further enquiries. This is a vulnerability in vetting procedures.
46	The Metropolitan Police Service's willingness to accept a decision that an uninvestigated allegation of indecent exposure did not warrant further exploration during the vetting process is of serious concern to the Inquiry
47	Wayne Couzens’ accidental TASER discharge was not a missed opportunity to prevent his further offending.
48	To assess suitability to work as an authorised firearms officer, careful and proactive supervision is required, rather than a reliance on self-disclosure by officers about financial issues.
49	The risk assessment carried out on Wayne Couzens by the Metropolitan Police Service when determining his suitability to be authorised to carry a firearm should have been more robust and not reliant on the vetting process.
50	The Metropolitan Police Service did not carry out a formal psychological assessment of Wayne Couzens’ suitability to be an authorised firearms officer. This was in accordance with policy at the time.
51	The opportunities to earn overtime in the Parliamentary and Diplomatic Protection Command may have disincentivised Wayne Couzens from seeking support for his welfare.
52	Sergeants supervising Wayne Couzens as an authorised firearms officer were not trained to assess an officer's state of mind or offer welfare support.
53	Wayne Couzens’ suitability assessment to become an authorised firearms officer at the Metropolitan Police Service may have been less rigorous than if he had applied for a firearms licence as a member of the public.
54	The Metropolitan Police Service did not receive or request an independent assessment of Wayne Couzens’ suitability to be an authorised firearms officer by someone within the force who had substantial experience of working with him.
55	Those assessing Wayne Couzens’ risk to be authorised as a firearms officer were not able to access information about the 2015 indecent exposure allegation. If they had, it is likely his application to be an authorised firearms officer would have been rejected.
56	Gaps in the way information is recorded and shared meant red flags about Wayne Couzens’ unsuitability to join the Parliamentary and Diplomatic Protection Command were missed.
57	Wayne Couzens’ spending was often excessive and impulsive, and he used loans and credit cards to manage his debt.
58	Wayne Couzens’ financial difficulties started well before he joined the police.
59	If more information about the particulars of Wayne Couzens’ Individual Voluntary Arrangement had been made available by him during the vetting process for the Civil Nuclear Constabulary, it is likely to have reinforced the assessment of an individual who was vulnerable financially.
60	It is likely that Wayne Couzens entered into the 2007 Individual Voluntary Arrangement in order to increase his chances of passing force vetting. It is also likely that he was unaware of the relevant vetting guidance stipulating that an Individual Voluntary Arrangement should have been a barrier to clearance.
61	Wayne Couzens may have consciously chosen an Individual Voluntary Arrangement over bankruptcy as a way of demonstrating that he was taking a responsible attitude to his debts, and because he believed that bankruptcy would preclude him from employment with the police.
62	Wayne Couzens engaged in deliberate deception to ensure that he passed the financial checks that were a part of the application and vetting process at the Metropolitan Police Service.
63	Two errors were made by Shared Services Connected Ltd when calculating Wayne Couzens’ salary, resulting in him being paid significantly more than he should have been by the Metropolitan Police Service.
64	The fact that errors in Wayne Couzens’ pay were not discovered earlier may have been due to a lack of oversight and governance controls.
65	Wayne Couzens appears to have been under unprecedented financial pressure at the time of the abduction, rape and murder of Sarah Everard.
66	At key moments of scrutiny, Wayne Couzens was able to present with a ‘veneer of solvency’. It is a matter of concern that the vetting and aftercare process did not reveal the longevity or extent of his indebtedness.
67	Financial difficulties can create a risk to mental health, which may affect individuals’ ability to perform their professional duties. This risk was not explicitly considered during Wayne Couzens’ vetting.
68	Police officers’ perceptions of the Parliamentary and Diplomatic Protection Command varied and were informed by their personal experience.
69	By the time Wayne Couzens resigned from Kent Special Constabulary, he already had a history of abusive and potentially criminal sexual activity against women.
70	There is insufficient evidence to draw broad conclusions about the culture at the Civil Nuclear Constabulary when Wayne Couzens worked there. Couzens’ contributions to the WhatsApp group with other former Civil Nuclear Constabulary officers provided an indication of an unhealthy culture between those officers, in which they felt comfortable sharing obscene, derogatory and discriminatory comments of an extreme nature.
71	Wayne Couzens was selective about when and to whom he revealed views and opinions that were at odds with the Code of Ethics and which fell below the high standards of professional behaviour expected of those who serve in the police.
72	The contributions of Wayne Couzens’ colleagues to the WhatsApp group that featured in the Independent Office for Police Conduct’s investigation, known as Operation Argens, amounted to serious offences, and some resulted in prison sentences.
73	One of Wayne Couzens’ comments to colleagues in the WhatsApp group is not only grossly offensive but also, viewed in the light of his later crimes, chilling.
74	Wayne Couzens was abusing women long before he joined the police and is likely to have victimised more women than have reported such allegations against him.
75	Although Wayne Couzens was not wholly a product of his working environments, those environments did nothing to discourage his misogynistic view of women and meant that, as long as he presented himself as professional, his deviant behaviour outside of work could flourish.

Part 2

In May 2023, the terms of reference for Part 2 of the inquiry were set to look at the "recruitment and vetting of police officers, culture and standards in policing, and measures to help prevent sexually motivated violence against women in public spaces."