Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697750595767.pdf (Ireland)
Statement to the Joint Committee on Justice & Equality – Ms Laura Galligan Chairman, members of the Committee, thank you for the opportunity to address the Joint Oireachtas Committee today to discuss current issues relating to the recording and classification of Garda homicide figures.

I am a Senior Crime & Policing Analyst in An Garda Síochána.

I work within the Garda Síochána Analysis Service referred to as GSAS, and am attached to Special Crime Operations.

I have been in this position since June 2016.


Prior to this, I worked in the position of the Senior Scientist in the Office of the State Pathologist from 2012 - 2016.

I had the sole responsibility for the management and running of the laboratory where I performed all histopathological tests on samples from state post mortems performed by the State Pathologists.

I also accompanied the forensic pathologists to crime scenes, and assisted them in the post mortem examinations.
My educational background includes Medical Science and a post-graduate in Forensic Medicine.

I am currently undertaking a Professional Certificate in Governance.

In July 2016, my line Manager Ms West assigned me the task that the Garda National Protective Services Bureau had requested – a ten-year Domestic Homicide review (2007 – 2016).

Ms West had from the outset expressed general concerns about the data quality on the PULSE system.
To prepare for the assessment of how this ten-year review could be undertaken, I carried out an initial overview analysis of what information was contained on PULSE in regards to the Homicide categories.

This involved understanding how easily identifiable it would be to recognise a homicide that had a domestic element.

A meeting was held in September 2016 with the Chief Superintendent of the Garda National Protective Services Bureau to discuss the action plan of this task.
With prior permission from Ms West, I suggested working in collaboration with the Office of the State Pathologist as from my previous experience, I was aware the office’s records may contain more information on whether there was a domestic element to the death, which would greatly assist me in undertaking the ten-year review.

This suggestion was very much welcomed by the Chief Superintendent and other members within the Garda National Protective Services Bureau.
I had met with the State Pathologist Professor Marie Cassidy to ascertain her interest in the work, and then wrote to her on the 8th September 2016 requesting an agreement to collaborate data and information to carry out this review between the Office of the State Pathologist and the Garda Síochána Analysis Service.

On 14th September 2016 Professor Cassidy wrote to me to confirm her agreement to the collaboration.
I would like to take this opportunity to personally thank Professor Marie Cassidy, Dr Linda Mulligan, Dr Michael Curtis, Dr Margot Bolster and all the staff in the Office of the State Pathologist for accommodating this review and the professional support and advice they have offered me continually.

I wrote a document entitled ‘Domestic Homicide Review Proposal’ which was sent to Ms West and the Chief Superintendent in the Garda National Protective Services Bureau.
I set out the methodology I would utilize to conduct a comprehensive analysis possible, and designed a template qualitative data sheet.

In addition, on a monthly basis GSAS would produce an internal Homicide Spreadsheet.

In 2016, I was the analyst responsible for this in the months September, October, November and December.

In the 4 months I produced this spreadsheet, I noted the absence of a number of homicides from 2016, and that they were recorded as non-crime incidents of Sudden Death.
At the beginning of October 2016, I commenced my analysis utilizing records from the Office of the State Pathologist, information on PULSE, and the homicide spreadsheets produced by GSAS on a monthly basis for internal use.

When I reviewed the post mortem report and the circumstances surrounding the death, with consultation if required with the relevant Forensic Pathologist, I scrutinized PULSE for the recording of the death and other data quality parameters.
I began on the year 2014, for no particular reason, and quickly realised that there were inconsistencies evident with homicide and death classification, and many data quality issues.

I immediately raised my concerns with my line manager Ms West.

Following a period of 3 weeks in October 2016, when I was abroad on training for An Garda Síochána in Belgium, I resumed the Homicide review in November 2016.
Ms West asked me to specifically consider a period of 3 years to ascertain any inconsistencies and the varying issues I had identified.

We decided to conclude with a sample of three years, as it was pertinent that this issue was raised to Garda management as soon as possible.

On 24th November 2016 I emailed an 87-page report entitled ‘Comparative Analysis of the Recording and Reporting of Homicide Incidents in the PULSE Database and the Office of the State Pathologist’ to GSAS management.
This report was in regards to 43 cases that I identified within the time period of 2013 – 2015.

I had reviewed 524 deaths in total for this period.

These 43 cases were not identified as all being potential homicides.

There were many areas of concern in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues.
Broadly speaking, there were four areas of concern –     Deaths that were considered pathologically to be a Homicide but were recorded in the incorrect crime category and / or a non-crime category – this was a total of 14 deaths Deaths that were recorded at a later date as a Homicide and/ or were recorded as occurring in the incorrect year.
Deaths that the cause of death deemed it suspicious and the Garda investigation would ascertain whether criminality was involved or not – these were recorded in a non-crime category or no category at all Deaths that had varying Data Quality issues – e.g.

the deceased not being marked as deceased on PULSE, the deceased having the incorrect ‘weapon used’ recorded, deceased having an incorrect Date of Birth recorded, incorrect Garda district / division recorded for the death.
In mid-January, 2017, a review group was created with officers from Policy Development, Implementation and Monitoring (PDIM), Ms West and I. PDIM said 2 of the 43 deaths that I had raised with issues in the report from 2013 – 2015 would not be considered in the review, for reasons that cannot be disclosed publically due to legislative frameworks.

This resulted in the 41 cases being the subject of review between PDIM and GSAS.
As mentioned by Ms West, a total of 9 meetings occurred between January and March 2017 with individuals from PDIM, Ms West and I.

These meetings did have very robust discussions, and we voiced our concerns at what we deemed to be a very serious issue regarding the recording and classification of deaths within An Garda Síochána.

Professionally I felt neither Ms West nor I were given the respect we deserved.

Indeed, at times I felt we were belittled and treated very poorly.
During these 9 meetings, at no stage was the methodology I had utilised, questioned by members in PDIM nor was it referred to as weak.

During these months, I began interrogating the PULSE database to try to determine a little more background on how deaths can and are being recorded in An Garda Síochána.

I identified that there are 16 incident categories on PULSE that a death could potentially be recorded under.
I considered this to be a significant number of ways to record a death, and they were extremely varied in their descriptions according to the PULSE Creation Manual.

I continued to analyse the PULSE Database, and I discovered that there are no identifiable parameters on PULSE for fatal Hit & Run incidents or even non-fatal Hit & Run incidents.

On inspection of some examples of fatal Hit & Run incidents, they are all being recorded as Traffic Collision Fatal incidents.
This is a non-crime category, yet there is a criminal investigation initiated from the time of this incident occurring.

I had raised these issues among many others during the 9 meetings with PDIM, but we were told quickly they weren’t up for discussion and it was only the 41 cases that were to be reviewed.

We felt that the varying issues that I was identifying were critical to highlighting the facts of misclassification in the recording of all types of deaths.
In January 2017, I had continued the analysis of deaths in the year 2012, and wrote an 81- page report on various cases with serious anomalies, and sent it to Ms West.
Areas of concern were consistent with the previous report and others identified were –    Deaths recorded in non-death categories – Missing Persons, Public Order Offences, Attention & Complaints Deaths being counted twice Deaths not recorded for significant periods of time after the deaths had occurred Although this report was also completed, PDIM gave strict instructions not to send it to them as they were not reviewing any more than the 41 cases from the three-year period.
Within this timeframe, I identified other issues that I raised immediately to various individuals in management:   I raised an incident of serious concern to the notice of the Garda National Protective Services Bureau, upon discovering the partner of a deceased person was in a new domestic violent relationship.

Since then, I have highlighted a number of these types of cases to GNPSB.

This led to the establishment of Operation Devise, which I have been involved in.
I highlighted an incident that I had discussed with the Chief Superintendent in Garda National Protective Services Bureau, that was recorded as a non-crime incident but was in fact a domestic Murder-Suicide incident.

Following inquiries, made by the Chief Superintendent, with the relevant Division, the incident was reclassified appropriately that evening.

In February, I had a routine meeting with my manager Ms West.
During this, I expressed my concerns at GSAS continuing to produce the monthly homicide spreadsheet, as we could not guarantee the accuracy of PULSE.

It was agreed with Ms West that I would review January 2017 in collaboration with Professor Marie Cassidy and the Office of the State Pathologist, to compare the cases carried out and the corresponding PULSE incident recorded.

In March 2017, I wrote a report entitled ‘Data Quality Issues with Death Classification 2017’, which was sent to management.
There were many areas of concern in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues.

There were 3 unrecorded homicides as of the end of February 2017.

One of the unrecorded homicides was raised at a Senior Leadership meeting the next day.

It still remained recorded incorrectly for a further 6 months’ despite being highlighted numerous times.

There were cases with the following data quality concerns: 1.

2.

3.

4.

5.
2.

3.

4.

5.

Homicides Misclassified Suicides Misclassified Hit & Run Classification – recorded as non-crime Traffic Fatal incidents Suspicious Deaths under Sudden Death Classification Natural Deaths – containing PULSE data quality issues At the end of April 2017, I was extremely surprised when it was announced in the media that the review into homicides was complete, and the conclusion was that there were only “minor misclassifications”.
It was at the public Policing Authority meeting on 27th April that we became aware there was a report that the ‘review team’ had written.

Neither Ms West nor I, as part of the review team, had any input nor were our views taken into consideration in the drafting of the report.

On receipt of the report on the 8th of May it became immediately clear why the report was not shared with Ms West and I.
On reading of the report, I felt very personally insulted with the commentary regarding my work and my methodology.

As previously mentioned, at no stage during the nine meetings was any criticism voiced regarding the inappropriateness of my methodology.

It was now concluded that the methodology I had utilised in comparing the records of the Office of the State Pathologist and the PULSE system were “inherently weak”, “inappropriate”, “confined” and “restricted”.
The days between the 8th and 10th of May were troublesome, in that PDIM brought significant pressures to sign off on the report that we had only just received.

Like Ms West, I professionally and ethically could not agree to a report I knew was completely inaccurate and misleading.

I remained assured that there were homicides misclassified and incorrectly recorded.
In May 2017, I wrote a report entitled ‘Homicide and Suspicious Death Incidents 2017: PULSE Categorisation & Office of the State Pathologist Categorisation’, which was sent to management.

There were many areas of concern continuing in misclassification, under- reporting, over-reporting, delay in recording, and data quality issues, such as:  13 Homicides recorded as of May 2017 – 3 of which didn’t occur in 2017; but would be counted by the CSO.
 6 unrecorded homicides – recorded as follows: Non-crime incidents of Person Misadventure: Sudden Death Non-fatal incidents of Assault Causing Harm Non-fatal incidents of Discharging a Firearm  There are a number of fatal Hit & Run traffic incidents in 2017, all of which are unidentifiable in the recording on PULSE.

These incidents are routinely recorded as a non-crime incident of Traffic: Traffic Collision FATAL, when a criminal investigation is ongoing.
In the email sending this report, I stated “There are many victims going unnoticed by this organisation the longer this goes on.

When these cases are being recorded as a non-crime category of Sudden Death or even Discharging a Firearm, is there any follow up with the victim’s family or liaison with a FLO.

Is there even a FLO being assigned?

The deceased victims have not been given the respect and duty of investigation into their deaths that they deserve.
Sadly, the majority of 2017 homicides are of a domestic nature, again going unreported.

This is 2017 in four months…2013 to 2015 we are now satisfied that Crime Policy have reviewed, but see nothing but ‘minor inaccuracies’, which is completely incorrect….

I am not going to lose my work ethic or determination over this, and one didn’t build Rome in a day.
However, I cannot continue to identify incidents of homicide as we continue in 2017 that are not recorded correctly or not knowing whether there is an adequate investigation being carried out into that person’s death.” In June 2017, I wrote a report entitled ‘Homicide and Suspicious Death Incidents 2017 – Month Ending May 2017’, which was sent directly to senior Garda management.
There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as:  18 Homicides recorded as of May 2017 – 3 of which didn’t occur in 2017; but would be counted by the CSO.

 6 unrecorded homicides, still unchanged from previous report.

 10 suspicious deaths being recorded under a non-crime classification, although a criminal investigation is initiated.
 A number of fatal Hit & Run traffic incidents in 2017, all of which are unidentifiable in the recording on PULSE.

These incidents are routinely recorded as a non-crime incident of Traffic: Traffic Collision FATAL, when a criminal investigation is ongoing.

In July 2017, I wrote a report entitled ‘Homicide and Suspicious Death Incidents 2017 – Month Ending June 2017’, which was sent directly to senior Garda management.
There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as:  20 Homicides recorded as of May 2017 – 3 of which didn’t occur in 2017; but would be counted by the CSO.

 9 unrecorded homicides, recorded in non-crime or a non-fatal crime incident type.
 10 suspicious deaths being recorded under a non-crime classification, although a criminal investigation is initiated.

 A number of fatal Hit & Run traffic incidents in 2017, all of which are unidentifiable in the recording on PULSE.

These incidents are routinely recorded as a non-crime incident of Traffic: Traffic Collision FATAL, when a criminal investigation is ongoing.
In August 2017, I wrote a report entitled ‘Traffic: Dangerous Driving Causing Death Incidents: PULSE Categorisation analysis 2003-2017’, which was sent to management.

There were many areas of concern in the recording of the Dangerous Driving Death incident type over the years 2003-2017.

Also in August 2017, I wrote a report entitled ‘Review of 2006 Homicides – Murder and Manslaughter: PULSE Categorisation Analysis’, and sent this to GSAS management for onward transmission.
This was an overview document regarding the adherence to Crime Counting Rule 3.1 in the year 2006.

As per HQ Directive 139/03, 3.1 states ‘A reclassification within homicide occurs where a murder is reclassified to manslaughter when a charge of manslaughter commences or when a murder charge results in a conviction for manslaughter.’ This review analysed conviction records and detection status for all homicide incidents also.
In October 2017, I wrote two reports entitled ‘Homicide and Suspicious Death Incidents 2017 – Month Ending September 2017’ and ‘An Analysis of Death Incidents – September 2017’, which was sent directly to senior management.
There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as:  37 Homicides recorded as of May 2017 – 7 of which didn’t occur in 2017 (Historical cases); but would be counted by the CSO.

 6 unrecorded homicides, recorded in non-crime or a non-fatal crime incident type.
A number of the previous highlighted mis-classified homicides had been reclassified to a homicide.

 11 suspicious deaths being recorded under a non-crime classification, although a criminal investigation is initiated.

 6 fatal Hit & Run traffic incidents are recorded in 2017, all of which are unidentifiable in the recording on PULSE.

These incidents are routinely recorded as a non-crime incident of Traffic: Traffic Collision FATAL, when a criminal investigation is ongoing.
 Queries why in some deaths with concerning details, that the State Pathologist was not requested  Deaths that should be classified as Suicide, or had already a Suicide Incident recorded (double counting) according to the detail in the narrative  Varying Data Quality issues In November 2017, I wrote a report entitled ‘Homicide and Suspicious Death Incidents 2017 – Month Ending October 2017’, which was sent to management.
There were the same areas in in misclassification, under-reporting, over-reporting, delay of concern continuing recording, and data quality issues, as well as new cases emerging that had issues, such as:  40 Homicides recorded as of October 2017 – 7 of which didn’t occur in 2017; but would be counted by the CSO.

 5 unrecorded homicides, recorded in non-crime or a non-fatal crime incident type.
 13 suspicious deaths being recorded under a non-crime incident, although a criminal investigation is initiated.

 A number of fatal Hit & Run traffic incidents in 2017, all of which are unidentifiable in the recording on PULSE.

These incidents are routinely recorded as a non-crime incident of Traffic: Traffic Collision FATAL, when a criminal investigation is ongoing.
 18 Traffic: Dangerous Driving Causing Death incidents recorded for 2017 – 4 of which didn’t occur in 2017, one has been incorrectly invalidated, and one has 3 fatalities but only one crime incident when there should be one for each victim.

 95 deaths in the month of October had varying types of data quality issues.

I have continued to highlight to the current day, cases that I believe are of concern in areas of Homicide, Traffic fatal incidents, Suicide, Sudden Death and indeed Homicide Attempts.
The classification of death incidents on PULSE requires an urgent review and needs to be simplified.

The review of the classification comparing PULSE and the Office of the State Pathologist is based on the pathological classification, but the ultimate arbitrator of the classification of death is the Coroner.

Unfortunately, at present the Coroners do not publish statistics.
I have now been directed to complete a review of all files in the Office of the State Pathologist from 2003 – 2017, totalling over 3000 deaths for classification purposes and investigation review using the methodology from the initial review.

I will endeavour to complete this as quickly as is possible, and also to complete the requested Domestic Homicide Review that was initially requested by the Garda National Protective Services Bureau.
Finally, I would like to thank you for the invitation to appear in front of the Committee today to provide clarity and context to the work that we do.

Addendum: (Will not be read out) On 24th November 2016, a report entitled ‘Comparative Analysis of the Recording and Reporting of Homicide Incidents in the PULSE Database and the Office of the State Pathologist’ was written.

A number of key findings were – 1.

A death by homicide recorded under the non-crime incident of Person Misadventure: Sudden Death.
In one particular case, the deceased also had an Assault Causing Harm incident recorded 7 weeks after the death; which was then invalidated, and an Assault Minor incident recorded over a year after the death.

These are unrecorded homicides.

2.


A death by trauma recorded under the non-crime incident of Person Misadventure: Sudden Death, and not reclassified to a Homicide incident till a significant period of time later – in one particular case the death remained as a non-crime incident of Person Misadventure: Sudden Death, and was not classified to a Homicide: Murder for 4 years.
In another case, the death was initially recorded as a Suicide, reclassified to a non-fatal category of Assault Causing Harm, and eventually reclassified to a homicide 2 years after the death.

3.

A death by trauma recorded under the non-crime incident of Person Misadventure: Sudden Death.

There was pathological evidence the deceased individual received an assault prior to the death.
In one example of death where this occurred, there were individuals recorded for being arrested and questioned for the Sudden Death incident.

There should not be people recorded as being arrested and questioned in relation to a non-crime incident.

4.

A death by homicide with the incorrect ‘Date Reported’ recorded.

The Central Statistics Office utilize the ‘Date Reported’ for their statistical purposes.
If a death has an incorrect ‘Date Reported’ it will inevitably result in inaccurate homicide statistics for that year.

5.

A death by trauma recorded under the non-fatal crime incident of Assault Causing Harm.

This is not a death classification.

According to Crime Counting rule 3.1 ‘A reclassification to a homicide offence (murder, manslaughter or infanticide) occurs when, for example a serious assault has been recorded and, some time later, the victim dies as a consequence of the assault.’ 6.
A death recorded correctly as a Homicide, but also an Assault incident created – therefore the crime is double counted.

7.

A death by homicide having a Homicide incident and a Person Misadventure: Sudden Death incident also – therefore the death is counted twice.

8.

A death whereby there was an incident related to a crime offence recorded for the deceased individual that occurred over one year after the death.

9.
9.

A death that is evidently the cause of Suicide being recorded as a Person Misadventure: Sudden Death instead of Person Misadventure: Suicide.

10.

A death recorded under a Public Order Offences category – this is not an incident type for recording a death.

11.

The deceased not being marked as ‘Deceased’ within a death category; therefore, not recognising the fact they are dead on PULSE.

12.
12.

A death of an individual that the narrative of the death incident contained a cause of death that was inaccurate in comparison to the post mortem report.

The suspicious circumstances surrounding the death were not explained under the non-crime incident of Person Misadventure: Sudden Death.

13.

Deaths that had varying Data Quality issues – e.g.


deceased having the incorrect ‘weapon used’ recorded, deceased having an incorrect Date of Birth recorded, incorrect Garda district / division recorded for the death.