Stephen Port inquest – The Coroners Summing Up

In November 2016, following a trial at the Old Bailey, Stephen Port was convicted of murdering four men – Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor.

They were aged between 22 and 25 years old and died in Barking between June 2014 and September 2015. Stephen Port was also found guilty of sexually assaulting a number of other young men. He was sentenced to life imprisonment with a whole life order.

HHJ Sarah Munro QC was appointed as HM Assistant Coroner on 1 May 2019 to conduct fresh inquests into the deaths of Mr Kovari and Mr Whitworth alongside the resumed inquests into the deaths of Anthony Walgate and Jack Taylor.

Evidential hearings started in the Barking Town Hall on 5th October 2021.

After 34 days of hearing evidence Her Honour Judge Sarah Munro QC summed up the case to the jury. This is what she told them:

[Taken directly from the transcripts published at https://www.eastlondoninquests.org.uk ]


Stephen Port was born on 22 February 1975. He is a gay man with a long-standing obsession with pornography, which by the dates with which you are concerned occupied almost all his waking hours when he was not at work.

You have heard from DI Richards how examination of Port’s laptop revealed his interest in pornography and how it developed into drug induced rape using GHB. You heard from Ryan Edwards that he met Stephen Port in 2005 and he lived nearby. Those two would meet over coffee about once a month and Ryan Edwards described Stephen Port’s what he described as a voracious appetite for meeting young men under the age of 23.

We are now on the chronology. From 2011 there were Skype messages on Port’s laptop consistent with him contacting males and arranging to meet them. The messaging suggests that Stephen Port was not taking drugs in June 2012, although by October that year he had stated that he had taken cannabis during a sexual encounter. As time went on, Port would arrange to meet young males on dating apps for sex and would watch porn right up to their arrival time and then pause while he went to the station here in Barking to meet them and then bring them back to his flat at 62 Cooke Street, where he would then resume watching the violent pornography and no doubt engage in sexual activity with the person he had met.

The evidence showed that he carried on such activity before Anthony’s death until shortly after Jack Taylor’s death.

In late 2012, Ryan Edwards founded the local Barking and Dagenham LGBT network and met up and communicated with DI McCarthy, who you will remember. He, Ryan Edwards, established a Facebook page and suggested that the nominated four LGBT police officers from the borough should add their names. Mr Edwards told you that there were around 80 followers and that he thought the Facebook page was still open in August 2014 and is, he believes, still open now.

That evidence, amongst other evidence, is relevant to your consideration of the question on the questionnaires relating to LGBT+ in the investigations.

Mr Edwards described, and you will remember this, an occasion when he went to Beckton with Stephen Port and the male described as X1, to a McDonald’s, when Port told Ryan Edwards that he was “Pimping X1 out”. On that occasion Port and Edwards left the McDonald’s without X1, leaving him there.

We then come to 31 December 2012, which is in bold on your chronology. The bundle reference is B/56, page 10. Just for your note, this is the PNC printout and it was entered on the CRIS, which is what we have here, by a PC McDonald — I am not sure that is right? Yes, it was entered on the CRIS on 26 June 2014. It reveals that on 1 January, so the very early hours of New Year’s Day 2013, X1, who had been in a relationship with Stephen Port for two years, called police saying that he had been sexually assaulted by Stephen Port who had given him poppers and alcohol the previous night and then had anal sex with him against his will. He stated that Port kept plying him with poppers and alcohol each time he refused to have sex with him, until he was unable to say no. On a few occasions he felt pressured into sex and that this was not the first time Port had “used drugs and alcohol” to take advantage of him. Port was arrested for rape that day. His DNA was taken and from then on would have been available – that is his DNA — to the police.

By 13.40, and this is on your chronology, on 1 January, X1 had said that he had wanted to withdraw his complaint and no further action was taken against Port. In his withdrawal statement, X1 maintained this account of being encouraged to drink large amounts of alcohol and be given poppers, which he was not comfortable with, but said he was too scared about how Stephen Port would react to say anything and he concluded by saying: “Stephen would not have known that I did not want to do these sexual acts, as I never said anything to indicate this, but I didn’t.” X1 then declined to make a statement to the police and you have all the detail about that behind divider 56.

Pausing there, members of the jury, the information about that previous allegation was known to the police within a very short time of the discovery of Anthony’s body. It was recorded by Detective Chief Superintendent Ewing in his daybook prior to 8.00 on 19 June. I will ask that that is brought up, that is divider 59 of bundle B. Next page, please.

This, you will remember, is headed 19 June 2014. This is Mr Ewing’s daybook and you will see about six bullet points up, “Caller: previous sexual assault”.

This was Superintendent Ewing recording in his daybook, on 19 June, before 8.00 in the morning is what he told you, that the caller, in other words Port, had a previous allegation of sexual assault. That is where that fits into the chronology.

DC O’Donnell agreed that he should have entered the details on to the CRIS and/or a current situation report so that that detail about the incident with X1 could have been seen by the HAT team when the matter was referred to them. This is what Mr O’Donnell told you, he said: “It was a fairly significant mistake that it was not included in the briefing document. Stephen Port had lied. Anthony Walgate had died of suspected drugs and there was intelligence that Port had previously raped with drugs.” He said: “I did think of going to see X1, but I didn’t. I should have.” You will need to consider that evidence in relation to consideration 2 under question 3 on your questionnaires, so that is where that fits in.

The laptop examination that was carried out by Operation Lilford, by Detective Constable Thomas, who you didn’t hear from but who Mr Richards told you about, revealed that by November 2013 Port is telling someone that he had taken a drug during sex that had made him “last a long time” and a few days later there are a large number of messages from X1 talking about them, him and Port, taking G together and trying a needle rather than drinking it.

By January 2014, Port is telling someone that he has taken mephedrone — a drug which you know features in the toxicology evidence.

During the first half of 2014 Port invited Ryan Edwards round on one occasion to meet a new boyfriend, who was called X4. That is when Mr Edwards says he was taken aback because there was a large tupperware container full of little vials of clear liquid like the ones found with Anthony and Jack and bags of light powder, also like the one found with Jack, and that on that occasion X4 was clearly highly intoxicated. That was the first half of 2014, according to Ryan Edwards.

We then come to 4 June 2014, it is the incident involving X3 and Barking station. On the Police National Database, so this is the PND, there was a British Transport Police intelligence report to the effect that on 4 June Port and X3 were stopped at Barking station following a report that Port was going through the male’s bag and had assaulted him. X3 was observed to be being violently sick and was very disorientated. Port said the following, that they had met on the internet and had been for a drive a few times. He said that he had found X3 outside his house.

He said that X3 had taken G and he said he had brought him back to the station in order to get him home safely and was going through his back to look for his phone.

X3 denied to police that he had taken any substance. You heard the statement which Operation Lilford took from X3 — indeed it is in your bundles, I think it is bundle 38A. In it he stated that he had met Stephen Port on the Fitlads website, or dating app, and visited his flat a number of times. He said on the fourth occasion that he had visited Port’s flat he was given a glass of Coke but that it tasted harsh and looking back he wonders if Port had put something in his drink.

He said the fifth occasion that he went there was 4 June, the day of the incident at the station, and on that day Port gave him what he thought were poppers, which he inhaled, and he then fell asleep for a few hours. When he woke up, Port gave him a drink of clear liquid which knocked him out straight away and when he woke up he was naked on the floor with an erection. X3 said he had to get home and Port helped him to the station and he remembered Port going through his bag. Later Port told him that what he had given him was a class C drug and in July when they met, X3 revealed in his statement that he had in fact recorded, taped, Port admitting that he had given him something. But thereafter he, X3, had deleted the recording because it brought back bad memories.

Pausing there, members of the jury, all that detail could have been obtained by the end of June 2014 if the police had done a PND check and traced and interviewed X3. DC Parish agreed that it should have been done. That evidence is relevant to consideration 1 under question 3 on your questionnaires. You will have noted that there are marked similarities between Port’s behaviour and account of that incident with what happened with Anthony Walgate, and of course it is less than two weeks before Port met Walgate.

Let’s turn to Anthony. He was 23 when he was murdered by Stephen Port. He hailed from Hull, but had come to London in 2010 to study fashion. He was living in Golders Green and he had three very close female friends, China Dunning, Ellie Green and Kiera Brennan. Anthony was very skinny. He had a size 30 waist and was on the very margin of a normal body mass index. He was committed to a career in fashion and by the time of his death was working hard for his final exams. He was openly gay but had no regular boyfriends, though he would occasionally meet males on Grindr. He was extremely open with his friends and they knew that from time to time he would act as a male escort when his student loan was running out, as it clearly was in June 2014, when Mr Richards told you Anthony had under £40 to his name.

Anthony was very safety conscious and would tell his friends who he was meeting and where and he would get his dates to send their details to him “for safety reasons”. Anthony tended to meet his date in a public place, such as a pub, before going to either his flat, a hotel or their homes. Generally he would message his friends when he was on his way or when he had arrived and when he left. Sometimes, if he stayed overnight with a client, he might sleep the whole of the next day so they wouldn’t hear from him, his friends, until the next morning when he finally woke up. China told you that his charges depended on who he was meeting and how long for. She said she thought it was between £200 and £400 for two hours. She said he was really picky about who he met and Ellie Green said that most of his clients were well off and in their 70s, men who treated him well and with respect.

China said that there was an occasion when a potential client mentioned chemsex. She said she and Anthony didn’t know what that was so they googled it and Anthony said that there was no way he was going there. Whilst according to China he used drugs very occasionally, a bit of cannabis and cocaine and ecstasy at a party on a handful of occasions, it was rare and she said he didn’t know where to get drugs in London.

She said he probably used poppers, which are not illegal, when he was acting an escort but no drugs, although he might have had a couple of drinks before he went to meet someone. She said he liked to be in control.

Pausing there to remind you of something that Sarah Sak, Anthony’s mother, said. You will remember Mr Slaymaker in his family liaison logs recorded Sarah Sak, Anthony’s mother, as telling him that Anthony would take cocaine on occasions. She denies ever saying that, although China gave the evidence I have just described.

China said that she and Anthony discussed drugs together fairly frequently. She said that she knew he had never taken GHB. She then said: “We were all of the opinion we would never risk it. It was super dangerous and easy to overdose on and certainly not with a complete stranger who was a client.

I just absolutely knew he wouldn’t do it.” China and I think Kiera too told you that when Anthony went out as an escort he would take a small knife with him for protection, and there is reference to that in some of his messages. Kiera gave a very similar account to that of China and she too had no knowledge of Anthony ever using GHB.

We then come to the days leading up to the meeting between Stephen Port and Anthony. Looking back at your chronology, on 12 and 13 June Port was watching gay sex videos and visiting gay dating sites.

Just after 1.00 on 13 June — this is not in the documents you have, so this is the only reference you have to this matter — he referred to a sexual encounter with a male, I think it was X1, who just wanted to “get high on G and so it was like fucking a rag doll”. That message was followed by many internet searches, which continued all morning and into the afternoon and evening. The search included “Sleeping pills”, “Drugs”, “date rape drug porn”, including, “Boys being fucked on G”, “Gay boys drug fucked asleeping”.

At 23.19 Port accesses the Sleepyboy escort app and contacts eight male escorts, including Anthony. He sends a message to them saying: “Are you free to come to Barking Tuesday night  [which would be the 17th] for an overnight? Please send some pics. Joe.” You know that was the name he was using, Joe Dean.

During 14 and 15 June Port carried on accessing porn, including unconscious boys being raped, then at 23.09, on the 15th, he viewed Anthony’s profile and then Anthony replied — this is at B/57 — referencing his profile and Anthony, as you know, was on the app as Ryan.

As you see on your chronology at 23.11 on the 15th, Anthony also asked for Port to send him — who he thought was Joe Dean – a photograph for safety reasons.

Thereafter Port carried on searching for boys being raped, drug raped, unconscious.

We then come to 15 June, which was the Sunday. Go back to China and what she said about this. China said she was with Anthony when he was communicating with Joe Dean and she said that he, Joe Dean, had agreed to pay about £800 for one night and said that he lived in Barking and China said no one has £800 for one night if they live in Barking, it was too good to be true. She said we did a Google search on the address and it wasn’t an affluent area. There was no attempt to negotiate a lower price, which we thought it was suspicious but when Anthony queried how he had so much money, the man they thought was Joe Dean said he was house sitting for a friend who was in South Africa, and China said, “I think Anthony believed that”. She said the man, Joe Dean, sent a photograph in response to Anthony’s request, which she, China and their friend Kiera saw. It showed in fact Stephen Port in a blond wig. Kiera told you that she thought Anthony was attracted by the amount of money. Turning to the question as to whether Port could have in fact have afforded that, we know again from Operation Lilford and Mr Richards’s evidence that Port had no means to pay that sort of sum, in fact he was £1,500 overdrawn in June 2014.

Going back to bundle B, divider 57, we know that Port in fact posed as Joe Dean of 72 St Ann’s Road, Barking, IG11 7AF, which is in fact the correct postcode for 62 Cooke Street. We know he gave an incorrect date of birth as 2 February 1986, his true date of birth being, as I told you just know, 1975, no doubt to try and make out that he was younger than he truly was in order to attract younger males.

China and Anthony stayed in touch over WhatsApp and he sent, as was his custom, both China, Ellie and Kiera, the details of Joe Dean and the address. To Ellie Green he accompanied the details with the message, “In case I get killed”.

We come then to 17 June, the Tuesday. Again on that day, Port was viewing pornography in the early hours of the morning, including “drugged, fucked and raped” and gay rape videos. China said she knew that Anthony was coming to Barking on that Tuesday evening and he had told Ellie that he was going to take a small knife and some scissors with him, as again was his custom, for protection.

China said that she was expecting to get a message from Anthony the following day to say that he was leaving Barking, because the plan was for the two of them to meet up after she had finished a shift at her work in Soho. Anthony’s last phone use was at around 10.00 pm on the 17th, when he replied to a message from Ellie Green saying that he couldn’t talk because he was working. That was 13 minutes or so before he exited Barking railway station, and police discovered that from his Oyster card usage. You have that on your chronology on page 2, 22.13.

 After that, Anthony did not use his phone and it was either switched off or the battery ran out or it was put into aeroplane mode at 04.58 the following morning and the phone never again reconnected to the network. On a different topic, you heard from Port’s some-time flatmate called Glen Aldwinckle. He had been staying with Port at number 62 Cooke Street and sleeping on the sofa, but he was not there on the night of 17 and 18 June. You have his first statement in your bundle, behind divider 31. He made a longer statement to Operation Lilford, which was also read to you later in the evidence, and which included details of Port apparently trying to get another young man, X10, to take G and asking Glen Aldwinckle to get X10 to do so. He wasn’t called as a witness before you, members of the jury, and he wasn’t called as a witness at the criminal trial of Stephen Port either because, as Mr Richards told you, his reliability was questionable. So treat his statements with care.

We then come to 19 June. At 02.57 that morning, in the early hours of the morning, Port’s laptop logged off the internet and you may think very unusually it was not used again until 23 June.

At 4.05 he made the 999 call. You have the transcript at your divider 3. He gave the address of the flats opposite his own. He said that he was driving past in his car, something which you know in fact you cannot do, when he saw a young boy collapsed as if he had had a seizure or was drunk. He didn’t give his number to the call handler, but the call centre traced it.

The responder to that call was Anthony Neil from the London Ambulance Service. He was dispatched but initially couldn’t find the male that Port had described and the controller therefore rang Port back and in that call Port said that he was driving in his car park and that the male was definitely in Cooke Street.

Mr Neil came to give evidence before you and he said that he found Anthony at about 4.18, as you see him in the photographs which you have in your bundle A.

Mr Neil said he was obviously dead and in his view had been dead for some time, as he was extremely cold and his temperature, which he took with an ear thermometer, was 24 degrees and Mr Neil was to tell you normal was 36.9, so he was 24.

Mr Neil said: “The very general rule is that the body loses a degree per hour, but that depends on all manner of variables.” Mr Neil noted that Anthony’s T-shirt was rucked up, as if he had been pulled along was how Mr Neil put it. He covered the body with a red blanket and the police were called. The first two officers to attend were PCs Benson and Middlemiss. They arrived shortly after 4.18 also. Those officers both thought that there was a footprint mark on Anthony’s torso and that he had a swollen lip and blood in his mouth, but in fact, as it turned out, as you know, the footprint was a sign of decomposition called hypostasis. In fact, again there was no injury to his mouth, although there may have been some blood in his mouth caused by some sort of expiration when or as he died.

There was a black holdall with Anthony, which had his house keys in it. In the holdall were various prescribed medications but, as you know, significantly no mobile phone.

There was also a small brown bottle which had the residue of GBL, a substance which converts to GHB in the body, as later analysis of that bottle showed. In the event, that bottle was not packaged properly by the police so it couldn’t be tested for fingerprints or DNA. Inspector Learmonth was the duty inspector for the night of 18/19 June and once the call had been referred to the police by the London Ambulance Service, the CAD was created, which is behind divider 1 in your bundle B. Inspector Learmonth was obliged to attend any unexplained death. This is set out in the policies that you are very familiar with now behind divider 20 in bundle A and he had to apply the five building blocks, which you have seen several times. They are behind divider 21 and 23 in your bundle A.

From his attendance the inspector remains responsible for the incident. You will remember that the guidance says: “If there is the slightest doubt, then the event will be dealt with as a suspicious death and the advice of the borough detective inspector will be sought to resolve the issue. If it is at night [as it was here] that will be the cluster detective inspector.” Inspector Learmonth agreed that he knew that the manual at paragraph 2.2.1 says: “Less obvious scenarios include drug-related death. If the potential for these reports to involve homicide is overlooked, opportunities to gather significant material may be lost. Think murder.

“If in doubt, investigate as a homicide until the evidence proves otherwise.” HAT cars will attend all unexplained deaths which have suspicious circumstances and it is the DI who makes the decision whether or not to call the HAT car. Inspector Learmonth told you that he arrived about 4.30, was briefed by PCs Benson and Middlemiss, who told him about what they thought was the footprint and so at 4.33 Mr Learmonth declared a critical incident to ensure that all necessary steps were taken. He said that the position of Anthony’s body was at the very least unexplained and he concluded that it possibly was a suspicious death.

So, as per the guidance, he referred the matter to the cluster DI, who was DI Delaney, and as a result the HAT car was called.

He also, Mr Learmonth, asked sensibly for the CCTV to be checked to see how Anthony had ended up where he did, but no relevant CCTV was found. He also, Inspector Learmonth, generated enquiries to find out who had called 999. Stephen Port was identified as having been the caller at 5.16. His address was discovered at 62 Cooke Street, of course outside of which Anthony’s body was found.

Having discovered that, the police made repeated attempts to knock on Port’s door. He didn’t answer the door, though we know he was in fact inside. The cluster DI arrived at about 5.18 and then, as I have said, the HAT car was called. While the police were still outside Port’s flat, Glen Aldwinckle, his flatmate, turned up and let the police into the flat and they found Stephen Port apparently asleep in bed.

Inspector Learmonth had not heard about the previous allegation of sexual assault made by X1, which was on the PNC record. You then heard from DC Nikki Cross, who was from the HAT team, and she arrived at 5.20 and was briefed by the detective inspector, she arrived with other HAT officers.

At 6.07 on the CAD, the London Ambulance Service entered that the caller was — described the caller, so Port in his call was described as “unsure and apprehensive” and Inspector Learmonth in that context agreed that a person reporting a suspicious death may be a significant witness or may be a suspect. At 06.10, this is behind divider 10, PNC checks were done on vehicles relating to 62 Cooke Street and that information was entered onto the CAD.

Passing there, members of the jury, if a PNC check had been done on Stephen Port it would have revealed the X1 incident. If a PND check had been done, it would have shown the incident at Barking station on 4 June involving X3.

A PND check was done on Anthony, and could just as easily have been done on Stephen Port once his details were known.

Next to arrive was the crime scene manager, Ms Kynaston, from whom you heard. She waited until after the forensic medical examiner had pronounced life extinct before she carried out any further examinations and that was Dr Munro in the case of Anthony, who arrived about.40 in the morning. You have his notes in your bundle, and they are on the screen. He noted that the body was cold and that there was stiffness of the small joints, fingers, which indicated rigor mortis had set in. He told you in his view Anthony had been dead for up to eight hours or more and certainly more than four hours. He said it was unlikely that he was alive at 4.00 when the call was made. He was sure that he had told the officers that, although it is not in his notes, and you will see he noted, “Query epilepsy, probably non-suspicious”.

It was him that dismissed the foot mark that the officers thought they had seen and said it was hypostasis. He pronounced life extinct at 07.51 and he says that he told the officers — or he told you that he told the officers that he indicated to them that the death could have been due to epilepsy or drugs, although there is no mention of drugs in his note. He agreed that in a witness statement that he had made, he said, “The unusual possession the body could not be easily explained”, and he was sure that he had told the police that he thought the body had been moved.

 The crime scene manager carried out her examination of Anthony. She was concerned as it seemed to be the wrong place for someone to be sitting. She said there were no obvious signs of wounds or trauma, but there was bloodstaining on the right arm of his hoody, consistent with Anthony having wiped his mouth which had blood in and around it. There was no phone but there was an Oyster card and a bank card. She noted that he was wearing skinny jeans, which were buttoned up at the top, but that the zip was broken.

She arranged for the body to be taken away for a special post mortem, as arranged by the HAT Detective Chief Inspector Jones. Ms Kynaston said that she thought it was possibly a drug-related death. Meanwhile, inside 62 Cooke Street, DC Young was taking a witness statement from Stephen Port. That is at your B/8. In it Port maintained that he had worked a shift from 9.00 pm until 03.45, arriving home at about 4.00 am. He said as he approached his front door he saw a male lying on the floor, blocking the entrance to his flat. He tried to rouse him by slapping his face and he made a gurgling noise. He then lifted him up by putting his hands under his armpits and put him against the wall. He then called 999, went indoors and fell asleep. You will recall, members of the jury, that Mr Richards told you that Operation Lilford took a statement from Stephen Port’s line manager, a gentleman called Mr Worthington. That statement was taken in November 2015. Mr Worthington recalled an occasion which he described as three years before, which would of course be 2012, but a day when Stephen Port was due to come into work at 6.00 in the morning, and that he had called Mr Worthington and said that when he had tried to get out of his flats the door was blocked by a young boy and he said he had had to move him out of the way but that something wasn’t right and so he couldn’t leave him there. So he told his employer that he had called an ambulance. They arrived and found that he was dead and he said he had tried to leave for work when he was stopped by the police. Pausing there, that is information from Port’s line manager obtained by Lilford in November 2015, describing a call which he thought it was three years before, and of course it could have related either to Anthony or indeed one of the other deaths, so bear that in mind but I put it in there because that is what came from the employer when Lilford asked about Port’s work patterns. I have already reminded you that Chief Superintendent Ewing made notes about the finding of Anthony’s body before 8.00 on 19 June and recorded that he was told at a very early stage “Caller previous sexual assault”, we have already looked at that and it is on your screen. Which was obviously a matter of significance, as Mr Ewing agreed. He agreed too that it should have been recorded on the CRIS at that early stage, so that it was accessible to the investigating officers. In fact, that reference to that incident did not get on to the CRIS for another week.

I just want to mention now another officer, Inspector Harman. The reason I mention Inspector Harman is because he was involved in the Gabriel Kovari scene, but he also attended the Cooke Street scene on the morning that we are dealing with at about 8.00. He was made aware of what had happened by Inspector Learmonth and that a male in his early 20s had been found, but it was Mr Learmonth who was to retain responsibility, so Inspector Harman had no other involvement, but it is relevant to the question of whether there should have been a link made when he later attended the Gabriel scene.

DCI Jones of HAT arrived as well at about 8.00. He is PIP3 trained to investigate homicide, you know what that means now, and he recommended the special post mortem, due to the possible footprint, which it was thought to be at that stage. He said he was not briefed on any inconsistency between Port’s account about Anthony being alive when he moved him and Dr Munro’s view that he had been dead for up to eight hours, Mr Jones said I didn’t know that, and nor did he know that the London Ambulance Service had found Anthony to be extremely cold and with a very low temperature. He agreed that he ought to have told those things. He said that in his view the death was unexplained. Then he said: “Had I felt any information suggested the death of Anthony was a homicide I would have declared the death as suspicious and referred the investigation on to the on-call detective superintendent for further consideration.” It was then suggested to him that the following factors might have led him to treat the death of Anthony as suspicious.

Firstly, the position of Anthony’s body. Mr Jones’s response to that was that he didn’t see Anthony in the position in which he was found and in which we see him in the photographs, he said he wasn’t in that position when he saw him.

He also said that he didn’t know that Anthony’s flies were undone.

He said that he did know that Anthony didn’t have a phone, but didn’t think that was significant. He said he was not told of the previous allegation of rape.

But he said his HAT officers should have hoovered up, as he put it, all the intelligence at the scene in order to enable him, Mr Jones, and his team to understand what was going on.

I am just going to remind you of what Ms Mackay said in relation to Anthony. She said that to her there was a tension between Stephen Port’s account and the physical signs on Anthony’s body, his temperature, the hypostasis and the rigor mortis. She said that, those features, should have triggered further investigation. At divider 12 of your bundle you have Mr Jones’s advice. This was the advice he gave to the on call cluster DI, Mr Delaney, as to the way forward. 1, hold a special post mortem, 2, survey the scene to review the route taken by Anthony, , make enquiries about witnesses — could we have the next page, please, thank you — 4, obtain intelligence on Anthony and trace next of kin, 5, keep scene open until after the special post mortem, and, 6, investigation to remain with borough with support from homicide command.

That record of advice, as you will see, indicates, if you look in the box in the middle of the page, below suspects N/A there is an entry: “Intel being conducted by KG [that means borough officers] early intel suggests … Anthony lives in Hull.” That is the HAT officer recording that intelligence checks are being conducted by borough officers. DCI Jones signed that HAT return at around 8.30, but he said he would have kept the matter under review.

Then this, members of the jury, Mr Jones was asked about the X3 incident from 4 June at Barking station. He agreed that that information was “very impactive”. He said had he known about that, he believes that MIT would have taken primacy in relation to Anthony’s death. Had he known about the X3 incident at Barking station, he believes MIT would have taken primacy. You may think that is very important evidence when you are considering question 3(a) on the questionnaire.

Ms Mackay said that had the British Transport Police matter been discovered, she thinks the matter would have gone to HAT and the death would then have been properly investigated and that would have led to Stephen Port being charged.

We are then on to 9.30 on 19 June, on to your chronology. There was a Pacesetter meeting chaired by Temporary Superintendent Hamer of the borough at 9.30 and a gold group meeting was scheduled for the following day, but it never in fact took place. A gold group is designed to add broader value to an investigation. It provides senior oversight and involves the wider community, including independent advisory groups such as the LGBT, but that gold group was never held that day because, by then, the death was no longer being treated as suspicious, due to the fact that the suspected footprint had now been identified as being hypostasis. Just to note, in relation to an officer who was involved in that meeting, who was involved later, Inspector Joyce phoned into that meeting and he told you when he gave evidence that finding a dead young person in the street was rare, he said he thought he had come across roughly two such deaths a year.

Going back to China, Anthony’s friend, she said she had heard nothing from Anthony and was concerned but thought he might still be asleep but once it got to Thursday, she said she was worried and so she went to the police.

I am now going to deal with China and Kiera’s contact with the police on 19 June. This is 67 to 79 of the bundle.

China went to Golders Green police station at about 6.30 in the evening on 19 June. It was there that she was told of Anthony’s death. She gave the police all the details about Anthony and all the details about Joe Dean and Kiera joined her while she was there. She also told the police that Anthony had shown her a photograph of Joe Dean and she gave the police a description of him. She then took the police to Anthony’s address.

The same evening the police spoke to Ellie Green, one of Anthony’s other friends. She confirmed that she had been in phone contact with Anthony at about 10.00 the previous evening. So from then on the police knew that Anthony had had a phone at 10.00. Once they knew that from Ellie, they should have been alerted to the fact that Anthony’s phone was missing, you may think. You should note at this point too, members of the jury, that Detective Sergeant Turrell, Debbie Turrell from whom you heard, who was the officer in the case for Gabriel and Daniel’s investigations was also involved in Anthony’s investigations, in that she spoke to Ellie Green, but she told you that she made no link when she became involved with Gabriel and Daniel’s deaths back to the Anthony Walgate case.

We now move to 20 June, page 3 on your chronology, and we come to the special post mortem. DCI Jones was on leave that day, so he asked Detective Sergeant Southon to attend and the briefing is at divider 16. Both Mr Jones and Mr Southon agreed when it was put to them that as it would take months before the post mortem report was available, it is vital that police officers at special post mortems record all the relevant detail. For example, you will remember that there was a record made by the crime scene manager — I think I am right in saying — that Anthony’s underpants were on inside out and back to front, which was an important piece of evidence, you may think. They should also have recorded the finding of bruising, which, according to the pathologist, possibly indicated that Anthony was moved when he was still alive.

 The officers agreed that the bruising became more important once it was established that Port’s account was untrue.

In the oral briefing before the special post mortem they were told, those attending, that Anthony had gone to Barking for a sexual encounter. They also had Port’s account that he had dragged Anthony’s body, which they thought might explain his rucked-up clothing and the bruising found at the post mortem.

 The examination itself started at 12.00 noon, it was carried out by Dr Biedrzycki, who you heard from. His report was not in fact available until 23 December, because it couldn’t be completed until after the toxicology results.

The strategy at the post mortem was to establish the cause of death and to see if there was any evidence of third party involvement or if drugs or a weapon had been used. The pathologist told you that Anthony had a heavy brain and lungs, which are findings which are consistent with ingestion of drugs. He had recorded, or it had been recorded that there was “no sign of assault”, but the bruising under Anthony’s arms, possibly due to him being moved while he was still alive, and according to the doctor which must have been caused in life, but could have been caused while Anthony was unconscious or just on the point of death, should have been recorded. Dr Biedrzycki said that he would not be happy to give an estimate of the time of death from any findings that he made. Going back to Ms Mackay’s view about that, she recognised that that was the medical view, but she still thought that Anthony’s low temperature, the rigor mortis and the hypostasis should have led the officers to question Port’s version of events. She also took the view that the bruising could be a sign of an assault, and therefore third party involvement, which might indicate that the death was suspicious. She was critical of the brevity of the notes that had been taken and said that, of course, the swabs should have been sent off.

As I have said, the crime scene manager noted that Anthony’s underwear was inside out and back to front, which could have been due to someone dressing him. But she couldn’t say that it must have been. It was noted that Anthony was wearing a large size T-shirt. Port told the police in his interview that he had put one of his own T-shirts on to Anthony and Sarah Sak when she found that out, Anthony’s mother, said Anthony would never willingly have worn someone else’s clothes and had she known that the T-shirt Anthony was found in was a large size she would have told the police her view about that, but she wasn’t told that.

The crime scene manager advised that toxicology on the brown bottle should be carried out, together with DNA and fingerprinting, and it was her view that very likely drugs had played a part in Anthony’s death. On 10 September Denise Stanworth’s toxicology report was produced. It revealed that the levels of GHB in Anthony’s blood and urine were more than 200 milligrams per litre and she told you GHB was an anaesthetic drug, more recently it had gained popularity on the dance and club scene and has been implicated in date rape incidents, its effects start after about 15 minutes and may last several hours. It may depress you so much that you don’t wake up. It may lead to anaesthesia, coma and respiratory depression. She said: “The concentration here is high and within the range at which deaths from GHB intoxication have been reported and that it could account for Anthony’s death.” She said: “Anthony may have laid unconscious for several hours and therefore the concentration of GHB in his blood could have been higher at an earlier time.” The cause of death was given as GHB poisoning and when you look in due course at the record of inquest for Anthony’s case, you will see that that has been entered for you as the cause of death.

 The pathologist, Dr Biedrzycki, told you that GHB is notorious because of the small difference between a non-fatal and a fatal dose. With a higher dose the euphoria gives way to sedation and unrouseable sleep. You will recall, and I have already reminded you, that the bottle that was found with Anthony did have GBL in it, or traces.

You then heard from Detective Inspector Southon, who was a HAT officer who was at the special post mortem, he was there with another officer called DC Davidson, who was going to act as an exhibits officer from the HAT side of things. He agreed that it was important that a record was kept of all potentially relevant matters and that a full discussion took place with the borough officers. He agreed that Dr Biedrzycki pointed out the bruising to the pectoral muscles and everyone concluded that it was caused when Port picked him up and dragged him as he had described. The officer agreed, with hindsight, that bruising could be evidence of an assault and that he ought to have referred to it in his HAT advice, which he didn’t.

He said he didn’t remember any discussion about the sexual assault, but sex swabs were obtained and he, Mr Southon, advised that they should be submitted. He was not aware of any timing issue in relation to death being raised. His advice is set out behind divider 18. It included submitting the sex swabs and the bottle. It included making enquiries about Anthony’s phone, financial enquiries and research on Joe Dean. He told you that he knew that it was thought that Port might well be Joe Dean, which would mean that Port had lied to the police and that he would have had to be arrested and interviewed.

He said in relation to intelligence checks that borough officers can do their own crime intelligence checks and can access previous crime reports and information on what is called IIP, which can pull information from different police reports. He was then asked about the passage in bold at the bottom of the document that you have on your screens: “There is nothing to suggest that the victim has been assaulted. This investigation remains with KG  [meaning the borough] and SC&O1 involvement is complete.” He said that decision was made by Detective Inspector Hughes. He told you: “I think it was the lack of obvious cause of death or any evidence to say Anthony had been unlawfully killed that led to the borough keeping the investigation. There was no mention of involuntary overdose.” He agreed however with the guidance, which was to think murder. He said that the fact that Anthony was employed as an escort, that Port was in fact Joe Dean, that Port had lied to the police and that Anthony had met Port meant that in fact now it was too soon to rule out homicide. He said there were a number of enquiries that were still ongoing to try to find out what had happened and gathering of that intelligence is critical to homicide investigations. He agreed that his team had specialist officers who could gather intelligence and create profiles.

I am now going to turn to the borough investigation as it took place from 20 June onwards. This involved Detective Constable Parish, Detective Sergeant O’Donnell and Acting Detective Inspector McCarthy. DC Parish told you that he was tasked to do various things by Detective Sergeant O’Donnell, for example on 20 June he made enquiries into Anthony’s use of his Oyster card and both he and Mr Parish, so Mr O’Donnell and Mr Parish, attended the special post mortem, having been briefed by DI McCarthy. Mr McCarthy was then on leave until 25 June.

You have Mr O’Donnell’s notes behind 17, which includes notes about the underwear being inside out and back to front and includes actions such as, “PNC, IIP, fast track, Port = Joe Dean?” could we just have page 13 of that document on screen, please.

That is where those things are entered, on the right-hand side “PNC, IIP, fast track, Port = Joe Dean?” As well as other matters.

DS O’Donnell entered the result of the special post mortem on to the CRIS, this is divider 71, but did not refer to submission of the sex swabs as had been advised by the HAT team, so Mr O’Donnell enters the result of the special post mortem onto the CRIS but not the need to submit sex swabs, which is probably why that action got lost. He didn’t refer on the CRIS either to the position of the underwear nor to the suspicion that Port might be Joe Dean, and he agreed that those omissions were indeed all oversights by him.

On 22 June DC Parish went with China to Anthony’s flat in Golders Green and found out from China about Anthony’s escort work.

On 23 June DS O’Donnell, page 76, tab 2, records the investigation strategy for what he describes as a “suspicious death”. Reference is there made to recovering Anthony’s laptop and sending it for analysis. He also then referred to swabs being sent for analysis, as well as the sex swabs together with the bottle, which was at that stage wrongly believed to contain poppers. There was no reference there to Port being Joe Dean.

The family liaison officer in Anthony’s case was Temporary Detective Constable Slaymaker, who had never been a family liaison officer before, and as you know from Ms Mackay’s evidence a family liaison officer should always be a detective constable. He spoke to Sarah Sak. You have his logs. I am not going to take you to them but if you want to, you can read them through in due course. There are differences between what he says was said by him and to him and differences with what Sarah and others say was said to them and by them. Sarah says that she made it clear from the outset that she believed that Anthony had been murdered. She also says that she told him that Anthony would be glued to his phone, and therefore the significance of him not having a phone with him when his body was found. She also said she told Mr Slaymaker how safety conscious Anthony was after he had been mugged in London and that he would never take drugs voluntarily.

She says that she told or asked Mr Slaymaker to look at Anthony’s laptop, but that she was told that was too expensive. Mr Slaymaker refutes a lot of that detail.

On 24 June China spoke to Mr Slaymaker. She told him some details about where Anthony was going that night. She said that he had bought some poppers for that particular night and she said: “I remember being asked several times about drugs and I was saying he would smoke cannabis very rarely and socially, but not with clients, and I kept telling him that he categorically would not take drugs with a client.” On 25 June Mr McCarthy was asked to supervise the investigation and he was effectively in charge until he handed it over to DS O’Donnell on the 30th, so Mr McCarthy is involved from the 25th to the 30th. On that day, the 25th, China told the police that she was 97 per cent sure that the photograph of Port was the same male who had been described as Joe Dean and whose photograph she had been shown by Anthony. At that point the police know that China was 97 per cent sure Port was Dean.

Then, taking you to page 82, behind tab 2, this is the first reference on the CRIS to the previous allegation against Port, involving X1, referring to unconsensual anal sex with a male after making him take poppers and the CRIS refers to, “Currently awaiting full details”.

At page 116 of the same document Mr McCarthy set some actions for Mr O’Donnell, including, “Conduct intel research, PNC/IIP et cetera, on Port”. It was agreed by the officers that those checks should have been done on all police indices, including the PND. I have already referred you to the fact that earlier the borough police had managed to do intelligence checks on Anthony and had done IIP, PNC and open source checks on him.

Mr McCarthy said that he expected Mr O’Donnell to do it and to include in that check a PND check. Mr McCarthy also agreed that he should have ensured that Mr O’Donnell had carried out those tasks. In fact, the PNC printout relating to X1 was done at 16.01 that day. Then tab 20 — we are around 4.00 on the afternoon now of 25 June — I don’t think we have the right reference, but it doesn’t matter. One of the HAT officers had an email — I think it is tab 20 but it is not coming up on the screen. Don’t worry. There is an email in your bundle, which we can get the reference to in due course, which came from a lady called Syria Hussain, who was from the homicide command. She emailed DI Hughes, who was the officer who had signed off the HAT advice — this is it now, thank you very much. It is referring to a call to HAT from Mr McCarthy. You will see within this email Syria Hussain advised that in the light of the new information that Port was Joe Dean, they should be looking to arrest Port, secure his address, look for the victim’s phone and Port’s laptops and phones. Effectively, DI McCarthy was asking MIT to take the job on as it had now become suspicious. In the context of proper record keeping and so on, which is one of the at the topics you will have to consider, DI Jones told you that he knew nothing about this email. Pausing there, members of the jury, by this date, 24 June, Port had gone from being someone who found a body on his way home from work, to someone who had lied to the police, had been the subject of a previous allegation of male drug rape two years earlier and Mr McCarthy agreed that was a powerful basis for further enquiries. It should have led to a statement being sought from X1 and to all the intelligence being obtained. Mr O’Donnell also agreed that this was a very significant piece of information, the X1 incident, in the context of Port giving the victim drugs and raping him and the special post mortem findings of heavy organs consistent with drug overdose.

Ms Mackay’s view of the X1 incident was that this information was extremely significant, because it suggested a pattern of behaviour by Port and similar circumstances to those between Anthony and Port. Once it came to police attention, she said they should have been to X1 and taken a statement from him.

In relation to the PND check, which would have revealed the Barking station incident, Mr O’Donnell said it didn’t cross his mind, though he agreed it could easily have been done. He agreed that that was another serious oversight. As you know, had he done a check, it would have come back with the incident involving X3 on 4 June. The significance, the officer agreed, would have been immediately apparent to him and he told you, “It is a huge failure not to have got that report. It could have been done very easily by the Met Intelligence Bureau and had I seen this [the report from Barking] I almost certainly would have commissioned someone to go and speak to X3.” That is what Mr O’Donnell said, and I remind you X3 was a complainant, in the sense that he was one of the victims at Port’s trial.

We then move to DI Kirk, from whom you heard a number of times but in this context, of the Anthony investigation he said that his view was that this investigation was becoming more and more complex and needed investigation by others. He spoke to DCI Jones but he, Mr Jones, still didn’t consider it to be a murder.

DCI Jones was asked about a number of things and what he would have done had he known about them. He said had the toxicology reached him saying that Anthony had died of GHB intoxication, and remember the preliminary report of that was available before Gabriel’s death, then he, Mr Jones, knew that it was a known date rape drug and this would have called for further investigation, especially bearing in mind the previous alleged date rape incident. He agreed that in that context it would have been relevant that his friends, Anthony’s friends, had said he would never have taken GHB.

Mr Jones said had he known about the 4 June incident, with the similarity of Port assaulting X3 who he met over the internet, said he had found outside his home, who was under the influence and had been sick and that Port was looking for his phone, he agreed, as I have already reminded you, it was very impactive and that elements were strikingly similar to Port’s interaction with Anthony and that information might have made a difference to the decision on primacy. He said he would have wanted X3 to be spoken to.

He agreed, Mr Jones, that Port’s laptop was seized on 27 June and that the HAT advice was to “ensure it was submitted for download”. That was not done for 10 months, and when the short report was available from DC Parish it was lacking, as you know, in relevant detail. Mr Jones said that should have been done sooner and should have revealed the true picture and he agreed that the download of Port’s laptop would have been extremely important evidence in the investigation into Anthony’s death and, “Had I been aware of it, I would have taken over the investigation”.

 Pausing there, and just setting out for you the failures so far, which have been accepted (1) the laptop not being submitted for examination (2) the PND check not being carried out and (3) the relevance of the X3 and X1 incidents not being appreciated.

The evidence demonstrated that the MIT teams, the murder investigation teams, do have better qualified officers, better resources and access to the HOLMES system, which would have meant a proper investigation and nothing, as somebody described it, falling through the cracks, as in fact happened.

 Of course, had Stephen Port been charged with murder or homicide of some sort before August 2014, he would have been remanded in custody and Gabriel, Daniel and Jack would not have been murdered.

Moving on now in the chronology, we are on 26 June. Again, in relation to the PNC report, it had been printed but again the detail hadn’t been entered on the CRIS as it should have been. Nor was it included in a briefing document to Mr McCarthy. Mr O’Donnell in that context agreed that it was an understatement to describe it as useful intelligence. Again, he set out and agreed that Port had lied, Anthony had died of drugs and there was evidence that Port had raped with drugs. Again, he agreed that he should have gone and interviewed X1 and that the information now available from this made the other intelligence checks even more important.

Mr O’Donnell said had he known about the X3 report, he would have tasked somebody to go and speak to X3. At 8.05 that morning, so we are on 26 June, Mr Hamer emailed Mr Kirk and Mr McCarthy stating that it was his view, as at that morning, that MIT should now take over, and he referred to the matter being, “Forced if and when we arrest for murder” and he asked them to be “pleasantly demanding of DCI Jones”, saying at the end, “The aims for today are SC&O1 ownership, caller arrested and scene secured”.

Mr Hamer explained to you in the context of that email that he felt MIT needed ownership due to the complexity of the investigation. There was an unexplained death, there was a deceased with bruising and there was a lying witness. Of course this was before Port’s first interview, and Mr Hamer wasn’t even aware of the X3 incident or the details of X1’s allegation, nor the contents of Port’s laptop. He agreed, this is Mr Hamer, that all that together, together with the further inconsistent accounts in interview, would have made the case even more complex and made an even stronger case for MIT to take over and for Port to be arrested for murder.

DC Desai, who you heard from, is PIP level 2 trained he was tasked first of all on that morning to go and get a search warrant from the Magistrates’ Court to search Port’s address. The application for the search warrant included reference to the pathology indicating drugs and to a previous arrest for drug rape. The offences to which the warrant was to relate included, “The unexplained death of Anthony Walgate”.

At 10.00 that morning, Mr Desai went to the Magistrates’ Court and obtained the warrant. At 11.30 there was then a meeting at which Mr McCarthy tries to persuade Mr Jones to take primacy and Mr McCarthy records in his notebook, “Still not a homicide”. He said that that was a reference to what Mr Jones said to him at that meeting.

Mr Jones doesn’t agree with that. He says that he doesn’t recall there being any discussion about primacy that day.

The plan was, however, that the MIT team were to continue to assist, including providing a MIT officer to interview Port but as you know that never happened and in the event DC Desai carried out the interview. Port was arrested at 2.12 on 26 June. And at 5.30 that day, before the interview, the HAT advice was updated to record the arrest and it still said, “Borough to retain responsibility for this unexplained death investigation”.

The HAT east team were to be made available to provide urgent further advice or assistance over the weekend because the original team, MIT 20, who had been involved — could you take that down, please — were not on duty over that weekend.

We then come to Mr Desai’s interview of Port, and I am going to summarise some of what he said, you of course have it in your bundle should you want to read it again. You will remember one particular question from Mr Desai to Mr Port was: “To me, I am thinking you murdered him.” He told you in relation to that question: “I couldn’t be certain that he had murdered him, but it was going that way. It was all very suspicious to me.” That is what the interviewing officer said. That interview started at 17.48 and finished at 7.30. As I say, Mr Desai said he thought it was all very suspicious and that somehow Stephen Port had been involved in Anthony Walgate’s death and he had assumed that Mr McCarthy would refer it back to HAT after the interview. The points to note perhaps from that first interview of Port are that he maintained initially that he had worked an odd shift until 3.45 in the morning and arrived home to find Anthony’s body. You will want to consider whether that should have triggered enquiries with his employer, that assertion by Port, and Ms Mackay says it should have done.

 He described moving the body twice, holding him under his arms and dragging him and carrying him, but he denied knowing that it was a dead body at that time.

You will want to consider if you think it is relevant, should that have created a suspicion due to the pathologist finding bruises that had been caused in his view during life, and the evidence from Dr Munro and the ambulance that he was very cold, and according to Dr Munro had been dead for up to eight hours.

Port said in interview initially, it was not the Anthony I knew. He admitted taking mephedrone with X1 in that interview and then he suddenly said that he had met a guy called Anthony online who came round and had sex and left, but then he said the male he had found at 4.00 in the morning couldn’t have been the same boy. Then he went on to tell DC Desai that he had used – he himself used to act as an escort, charging a maximum of £350. Should that have set alarm bells ringing about the £800 agreed by Port with Anthony? He then began to give an account of Anthony wanting to take something, them having sex, Anthony being sick and then leaving Port’s address to go and see a friend in Barking, which we know now is obvious nonsense. Next, Port referred to, “The last time I was in prison I almost lost my job”. That is important, because it comes up in relation to the next interview. Then finally he changed his story, said that he put Anthony to bed and went to work, that Anthony was still in the bed when he got home and that he didn’t know what had happened to Anthony’s phone.

The upshot of DC Desai’s interview, members of the jury, was that Port was a liar, who had spent the last 48 hours of Anthony’s life with him, who had on the evidence you may think dressed him, propped him up against a wall and told a pack of lies to the ambulance and the police. Where did that or should that have left the investigation? After that interview, again a matter for you, the following matters needed to be investigated, you may think, including where was Anthony’s phone, financial enquiries about each of their financial situations, Port’s bedding and bins for signs of what he said had happened.

His employer should have been seen. Traces should have been made to find X1 and X3. And a further interview conducted, as we know it was.

 At 18.32 Mr Kirk updated Mr Ewing with the list of enquiries, including research on Port — you have that on your screen. He records: “Although there is nothing to suggest Walgate was murdered at this time, his phone is missing and we suspect Port has lied to us, so he has been arrested for perverting the course of justice and theft.” Mr Kirk and Mr Hamer both agreed in their evidence before you that full intelligence checks were very important and should have included the PND. Mr Kirk said: “We, the borough, had all reached a tipping point before this.” Mr Hamer said: “We were pushing for MIT to take it on.” He agreed that after the interview the investigation became even more complex due to Port’s further lies and he would have expected a further approach to MIT. The question of primacy did not end there. DCI Jones spoke to DI Kirk, the head of CID here in Barking. Mr Kirk made a number of requests for Mr Jones to take on primacy.

Firstly, for example, he said he had no suitably trained interviewing officers and he was concerned that it might be a homicide. Mr Jones said he told Mr Kirk to raise his concerns with Detective Superintendent Sweeney, who was the on-call detective superintendent, in accordance with the policy where there are disputes over primacy.

At 21.53 Mr Kirk did just that. He emailed Mr Sweeney, among others, asking for a HAT senior investigation officer and referring to, “The suspect having previous for plying male with drugs”. His words were that the death was “on the balance of probabilities, at the hands of another. I appreciate that a murder charge may not be the final outcome, but the investigation is becoming increasingly complex”. He provided detailed reasons as to why in his view MIT should take over, referring to the lack of resources on the borough. He said it needed access to the HOLMES system and a trained SIO to take over and he attached to that email the previous HAT advices and the current situation report, including DC Desai’s interview summary.

He told you that he wanted homicide command to take over the case, more and more information was coming to light. Mr Kirk did not receive a reply to that email.

Mr McCarthy and Mr Hamer were both asked about their views as to this and they said they completely agreed with Mr Kirk’s view that primacy should be taken.

That evening, the 26th, Detective Superintendent Sweeney telephoned DI Kelly — DI Kelly was one of the HAT officers from the MIT team from whom you heard — and Mr Sweeney told Mr Kelly about the death in Barking, so that his MIT team could continue to provide HAT assistance. He promised officers to assist and a MIT 7 support team came here to Fresh Wharf the next day and they included DC Levoir and DC Holt, who were in due course to carry out the second interview with Port. Pausing there, members of the jury, I remind you that we had planned that you would hear from Detective Superintendent Sweeney, but I concluded that for good reason he couldn’t in fact come to give evidence. You will bear that in mind when you are considering communications in which he was involved, because he hasn’t been asked what was in his mind, what he meant by certain things that were said and particularly in the important email that we will come to in a moment. Bear that in mind. We had wanted him to be here but he couldn’t, for very good reasons.

Before we come on to 27 June, I just want to remind you what Ms Mackay said in relation to the stage we are now at. She said Anthony’s death should in her view have been treated as suspicious. There were a number of unanswered questions, which included the bruising, lies told by Port, the fact that he may have been Anthony’s client, the missing phone which in her view was very important and the lack of contact with his friends, which was very unusual. Her view was that primacy should have been taken on 26 June, because the investigation was by then clearly complex, the skill set of the borough officers was such that they were not able to progress it as a HAT team could. The reference by HAT to it not being a homicide is no answer at all, because she said not all homicides are obvious. She said this needed a properly trained SIO and proper management of the actions, forensics and planning. Proper structure to the interviews, engagement with the family, all with the added benefit of the HOLMES system. Moving now then to 27 June, that morning Mr Hamer spoke to Mr Sweeney about primacy and he recalled that Mr Sweeney’s attitude was “not yet” rather than a firm “no”. He pointed out that Mr Sweeney was on call over the weekend if Mr Ewing, his superior, needed to speak to him and he agreed that it would have been helpful — this is Mr Hamer – had he set out the response in writing, either to Mr Kirk or Mr McCarthy. Remember it was Mr Kirk’s email to Mr Sweeney, among others, asking for primacy to be taken and yet he received no reply. We then come to the important Sweeney email at 10.43, which sets out Mr Sweeney’s approach to the Anthony Walgate investigation in some detail. I commend you to read that in full in due course. I am going to remind you of some of it, but not all of it. The important thing to recognise, members of the jury, is it didn’t go to the borough, it didn’t go to Mr Kirk, so he never saw this.

It is copied in fact to his superiors, and copied to DCI Jones and DI Kelly, who were both of course from the HAT team. It is set out at length, the decision that Mr Sweeney took, he said: “I have not taken that decision [in other words to take on the investigation] but have made what I consider to be a pragmatic decision to ensure that we clear the ground in front of us at present and then decide where that leaves us. I will then be able to make a proper assessment.” He then appoints DI Kelly from MIT 22, with DS Reeves and: “… as many DCs from MIT 7 that are required to support the borough in the following five things: “(1) interviewing Port.

 “(2) dealing with the crime scene.

 “(3) family liaison.

 “(4) tracing the victim’s missing phone.

And, importantly: “(5) reviewing the enquiries already undertaken.” Reviewing is something that Mr McCarthy, and indeed Mr Cundy, felt was something that was a failure here, the lack of a review, but that was the recommendation here.

The purpose of that, according to Mr Sweeney’s email, was: “… to ensure that nothing is missed and that the investigation has sufficient expertise to undertake the tasks. As these tasks are completed, it will hopefully shed light on the circumstances of the as yet unexplained death of Anthony Walgate. Should I consider that it points to a homicide more than a drug overdose, or that the investigation at that stage is beyond the capabilities of the borough, I will make the decision to take the investigation on and relieve the borough of any investigative role.” He then sets out his reasons for not taking on the investigation at this stage and concludes by saying: “Primacy will be regularly reviewed as the investigations undertaken produce results.” Despite all that, as you know, there was no review that we know about.

Mr Kirk was asked about this email, and as I have told you, he said he hadn’t seen it, but by reference to the ongoing review he said such a suggestion was rare but that he should have been told about it and copied into the email, because it was a reply, in effect, to his email to Mr Sweeney. He said when he returned to work after some days off he found out that the case had been left with his team and that the borough were left in the unusual position of investigating an unusual unexplained death which a senior detective, in other words him, had indicated was probably a homicide. He wanted to make sure that it was however properly investigated and that adequate resources were allocated, but he didn’t know that Mr McCarthy, to use a phrase that has been used, had stepped back within a few days and that the investigation had been left to Mr O’Donnell.

Pausing there, Ms Mackay disagreed with Mr Sweeney’s decision not to take primacy at that stage. But she did agree that the level of support that he offered in that email was a good level of support.

I will just go on to the end of this day and then we will break for lunch.

Detective Sergeant Reeves was only involved on 27 June, he was in the on-call support team, MIT 7, and he was asked to assist the borough and to supervise the DCs who were coming with him. Mr McCarthy was providing the tasks that the officers were to carry out, in other words to interview Port, to search his flat, to deal with the crime scene, family liaison strategy, tracing Walgate’s phone and reviewing the investigation. All those matters being the ones that are set out in Mr Sweeney’s email. He said indeed the aim was to ensure that nothing was missed and to enable Mr Sweeney to then review the decision on primacy, but he agreed there never was at least a documented review of that happening.

Mr McCarthy said that he didn’t know that MIT were asking for a review, because of course he was not copied into the Sweeney email either. As we have just noted, Mr Sweeney had appointed DI Kelly to come to the borough, but in fact he didn’t did so and he oversaw his officers by telephone. Ms Mackay said that was not appropriate and DI Kelly should have come here and carried out the supervision in person.

 Between 12.30 and 2.30 Port’s flat was searched, the laptop was seized, as was his phone, together with a pair of pants in the bin labelled “born4porn” and two folders of pornography, which the HAT officers advised Mr McCarthy they should be reviewed, although it never was.

Between 13.10 and 14.55 DCs Levoir and Holt were tasked to conduct what they described as a no challenge interview, although Mr McCarthy says he didn’t use those words. As you know, DC Levoir, who was PIP5 trained, but said she wasn’t performing that role on this occasion, took some handwritten notes of the answers that Port gave. She recalled that she had done a typed summary, but that has never been traced and the only reference on the borough documents is to her handwritten notes. You will remember she had asterisked a few parts in the interview notes as to things that should have been done, but there was no further report from those officers to the borough and there should have been, said Ms Mackay.

In that interview the officers expected to ask questions about what Port had said in his first interview about the last time I was arrested, but when they came to that topic he in fact volunteered not the information about X1 but the information about the incident at Barking station, which was clearly of the utmost importance.

DC Holt said that that information coming from the interview would have been passed over in the debrief to Mr McCarthy and to Mr Reeves, but Mr McCarthy said he wasn’t told about Port mentioning that Barking railway station matter. As I say, Ms Mackay says DC Levoir, first of all, should have done her best as a PIP5 interviewer to progress the investigation and there should have been much better feedback to the borough, with an evaluation of the interview and actions set with a view to a future challenge interview after the actions had been completed.

 She said in any event, on the other side of the coin, someone in the borough should have reviewed DC Levoir’s notes and noted the areas she had highlighted for future action and somebody should have followed up the Barking station incident, which Port had volunteered. Had they, of course, the BTP report would have come to light, showing that two weeks before Anthony’s death Port was exhibiting a similar pattern of behaviour towards a sexual partner.

In fact, there was no further contact between the borough and HAT after 27 June.

Following the interview, there was no challenge interview and Port was bailed until 5 August, and there were no further interviews until we came to Operation Lilford.

Members of the jury, I am going to pause there now and we will have some lunch.

 Could you be back, please, for 1.55.

 Thank you.

 (12.55 pm)  (The Luncheon Adjournment)  (1.54 pm)  (In the presence of the jury)

THE CORONER:

Welcome back, members of the jury. I thought we had finished 27 June, but we haven’t quite. If you are looking at your chronologies, we are at the bottom of page 4 and we have just dealt with the Levoir and Holt interview. I don’t know whether we can have on the screen tab 37, page 10, thank you, which records that the plan was to have a forensic strategy meeting during the following week, the week commencing 30 June, and the action was set, “His mobile phone and computer will require examination”, so that topic is still being recorded as something that needs to be done and Ms Mackay said that obviously should have been done. Then tab 36 is the HAT advice at 3.30 that afternoon, which you have on your chronology, which again is the advice from Detective Sergeant Reeves, and states, “Ensure suspect’s phone and laptop are submitted for download”.

 Mr Reeves said it was obvious what needed to be done with the laptop and he didn’t need to give any further guidance, he didn’t think, in that regard. You will see that halfway down the box in the middle of the page that is on the screen at the moment.

Then the question arose during the evidence as to whose job it was to get the laptop looked at, submitted and downloaded. Mr Parish told you he wasn’t allocated the task until 10 months later, on 24 April, and that when he did submit the laptop in April, a USB stick came back with it, with the data on it, which as you know, he recorded, but not in the detail and the necessary detail, that DC Thomas was to record in Operation Lilford.

DI Kelly said that he, in this period, spoke to Mr McCarthy several times and was providing him with officers who could help with firstly the search and of course the interviews that had happened that afternoon. But, as I reminded you this morning, Ms Mackay said that really in her view wasn’t good enough and DI Kelly should have spoken to the borough officers face to face, there should have been an open discussion so that he could have assessed the competence of the borough and their ability to do what was required.

DI Kelly said that the next step after the interview should have been to obtain the information which the interview sort of threw up, and to confirm or contradict Port’s account. He said that interview and those actions from it should have been followed up by Mr McCarthy with help from the murder investigation team. Then tab 37, page 11 is Mr Kelly’s review and that is on the screen at the moment, which included a referral to the LGBT IAG, Mr Hodgson, and he, Mr Kelly, said that he kept an open mind as to whether the death was murder or accidental overdose and he assumed that the appropriate enquiries were ongoing. Where we saw on the HAT return, “Intel being conducted by MIT 7”, that is at tab 36, in fact – the next page, I think — there is no evidence that that was being done by MIT. So, again, we have that situation that Ms Mackay described as things falling between the cracks.

Mr O’Donnell agreed that the failure to do those intelligence checks was “a terrible failure”, because it meant that they didn’t get the British Transport Police information. He said, Mr O’Donnell, that he thought MIT were doing it. Mr Kelly finally on the topic of primacy said that he expected that Mr Sweeney would take a final primacy decision at a later date, once the enquiries had been completed. Both Mr Reeves and Mr Kelly agreed that the information from the interview about the incident at the station should have been followed up by further intelligence checks and that then the investigation should have been reviewed, but none of the officers from whom you have heard has taken responsibility for any review and none was in fact carried out, as we know. Thereafter, the investigation, which Mr Kirk said he believed was a probable homicide, was going to be investigated by the borough and it was allocated to A/DI McCarthy. At tab 60 we have an email sent from Mr Hamer to Mr Ewing to update him. He said that that email did not refer to primacy, because Mr Sweeney’s email had said – or Mr Sweeney had said not yet and they had to move on with the investigation on the borough. He agreed he could have escalated that decision to above Mr Sweeney, to what they call ACPO command, but he didn’t do that. He said there was always an option for a further referral, but he assumed that there was sufficient resource for the required enquiries. He said it wasn’t unusual for an unexplained death to be allocated to a detective sergeant.

Mr Hamer concluded by saying he didn’t know that there was no further approach to the HAT teams and he would have expected that to happen if there were significant further developments.

We are now on 29 June. At tab 61 is an email which Mr Ewing sent over that weekend to Sean Wilson. This is an important email, you may think, members of the jury.

It is 29 June at just after 5.00, from Mr Ewing to Mr Wilson, who was the officer who was going to take over from Mr Hamer in July, so Mr Wilson, the addressee of this email, was the person who was taking over from Mr Hamer. The email, you may think, demonstrates Mr Ewing’s frustration at really the system that operated with MIT. He says: “In essence, I am really unhappy about this as a system of work. I think the concept of advice is flawed and would not stand scrutiny. My position on this is we should push for a PIP3 accredited SIO whenever there is any possibility of a homicide, not just ask for advice. We do not have such detectives on borough.” Ms Mackay agreed with the sentiments expressed by Mr Ewing in that email. The evidence was that if a qualified senior investigating officer is deployed to look into someone’s death, they are qualified to develop a hypothesis as to what may have happened and then develop actions to progress the enquiry around that, either to prove that hypothesis or to disprove it and that was not something that a lower level of accreditation could do. So it was agreed in the borough that what they needed was a properly accredited officer to carry out that exercise.

Then, on 30 June, Mr O’Donnell had a meeting with Mr McCarthy. This is tab 49, page 24. Again, reference was made to the forensics being submitted. Again, Mr O’Donnell agreed that the laptop was discussed, but at that point he said he thought it would be difficult to get it done at this stage, now that Port was only being charged with or only arrested for perverting the course of justice. However, Mr O’Donnell agreed again that there had been further failures, he hadn’t been to Mr Port’s workplace, he hadn’t read the interview notes to see the reference to Barking station and he agreed that the summary of the interview should have both been obtained and put on to the CRIS, which it never was.

Pausing there and before we come to July, Mr Kirk summed things up in the following way. He said he agreed that serious mistakes were made by his team in that there were no PND checks, that the laptop was not submitted, that there was no further interview and that there was a failure to action Mr McCarthy’s decision to refer back to HAT after the toxicology results were through. He said this investigation was clearly not dealt with appropriately, and he accepted that it became disjointed and opportunities were missed and that the borough investigation was stalling by the end of June. That was how Mr Kirk put it.

The next date on your chronology is 8 July. It was on that day that Mr Parish finally sent off the samples but not the sex swabs. He said he sent what he was told to send by Mr O’Donnell. The same day China Dunning’s statement was taken, which you have in your bundle. Ms Mackay said that Mr McCarthy’s decision to step back at that point was “a really poor one”, she said he should at least have reviewed the process every month, supported his sergeant and made sure that he had the resources which he needed.

The next date on your chronology is 5 August, which was when Mr Slaymaker, the family liaison officer, tried to get the toxicology results fast tracked, you have a reference to that in the logs, but was told that wasn’t possible. Then you in fact note that it was the following day, 13 August, that the preliminary notification came back in relation to Anthony’s toxicology, confirming that GHB had been found, but not the level of the GHB.

 At this stage, Port is on bail and he was on bail when he murdered Gabriel Kovari and Daniel Whitworth. We come to 28 August. DC Desai, the officer who had interviewed Port, went to the churchyard on the morning of 28 August, when Gabriel’s body was discovered, but he didn’t make any link with Anthony or with Port. We are still on the Anthony enquiry, although I put those dates in to remind you of how they fit into this story, and we are now to 1 September, when Mr O’Donnell prepared a report to the coroner in relation to Anthony’s death. He was asked about some of the details he had included in that report and it was suggested that they were misleading. He hadn’t mentioned the state of Anthony’s underwear, he hadn’t mentioned anything about the second interview. He had said, for example, Port had said he had not used escorts before when he in fact said he had. He refers to there being one record on the PNC, which rather played down, it was suggested, the importance of X1’s allegations and he agreed that he should have made clear to the coroner that the police were still investigating an unexplained death.

In relation to his lack of knowledge about GHB, Mr O’Donnell agreed that he could and should have made up for his ignorance about that drug by asking the toxicologist, Ms Stanworth, about it.

By submitting the laptop sooner, because the sooner it was done, the better and the sooner they would have had the material that we know was on there.

Thirdly, he should have considered China’s evidence that Anthony would never have used GHB.

The formal toxicology report came through on 10 September and I have told you and reminded you what that showed. That was then reviewed by Mr O’Donnell on 15 September. Pausing there, Ms Mackay’s view was that the receipt of the toxicology report was an ideal opportunity, as she put it, for there to be a review and a discussion and for decisions to be made about what needed to be done from then on. There should have been research done, she said, into GHB and expert advice sought from HAT and elsewhere, as well as information from Anthony’s family and friends.

 On 16 September, at tab 42, Mr McCarthy asked for there to be a further referral to HAT in relation to what he described as the suspicious death. There was no further referral to HAT. It didn’t happen, despite Mr McCarthy saying he told Mr O’Donnell and Mr Parish to do it, “Could you try and get the referral done ASAP, I think that time is of the essence due to the potential issues with the family”, but it wasn’t done.

On 18 September, Mr O’Donnell entered onto the CRIS that the file was to be passed to MIT or HAT for advice. Again, it was never done. That was 18 September, and two days later, on the 20th, Daniel Whitworth’s body was discovered.

On 21 September there is a note in Mr Slaymaker’s logs that China Dunning told him that if GHB was found she does not think Anthony would have taken that of his own accord. She said: “I was convinced Anthony’s death was suspicious. I knew he hadn’t taken drugs himself or overdosed and I was convinced that Stephen Port had spiked his drink or something and that it was suspicious. I was making those points clear to the police at the time, but the police came to the view that he was a gay young sex worker and assumed he took drugs and would be willing to take a risk. I tried to convince them not to hold that stereotype and that was not who he was.” On 6 October Mr McCarthy chased up on the HAT referral again, which he had been asking for since 18 August, and it still wasn’t done.

On 16 October Mr O’Donnell sent Mr McCarthy a current situation report and he said that in fact his view was that there hadn’t been a referral to HAT and the reason for that was that they were waiting for the final post mortem report.

In the context of the local police investigation, Chief Superintendent Ewing accepted that the approach of the local police could have been better and that that could have led to the earlier arrest of Stephen Port. He agreed that budgetary issues should not be used to excuse basic policing mistakes, as he put it. He did not accept that there were systemic failures, however he did believe that a PIP3 DI had been dispatched, though in fact we know DI Kelly didn’t in fact attend in person.

On 30 October, Mr O’Donnell sent Mr McCarthy an update for submission to HAT, but again it never happened. Mr McCarthy told you that he expected Mr O’Donnell to do it and he agreed it should not have fallen through the cracks. As Mr McCarthy put it: “It was a suspicious death which needed to go back to HAT …” But he didn’t think it was down to him to check. Mr O’Donnell then asked Mr Parish to complete the report for the CPS, which you have in your bundle. It was Mr O’Donnell who had decided that the charge should be perverting the course of justice and recorded, “Await CPS response and SC&O1 advice”.

Mr Parish said he was not asked to refer the matter back to HAT.

It was noted that there was now no reference to the laptop or phone being submitted and Mr Parish said those actions were missed. Again, we have references to there being lack of records, and one person not knowing whose job it was to do the action and another person saying it was that person’s job to do it.

That statement, that report, was then referred to Mr Held at the Crown Prosecution Service. He wanted to wait for the full post mortem before responding. That was then chased up, the report became available on 23 December and sent on to Mr Held on 2 January. The last entry on the CRIS was on 17 January. Mr Held told you that the report was sent to him in order for him to provide pre-charge advice concerning perverting the course of justice, the CPS role is not investigative, that is for the police to do. He said: “There is an option for pre investigative advice but that was not sought here.” Had it been submitted by MIT and the advice requested on murder, he said, “There is a threshold test in an emergency situation which allows for a charge and a remand in custody. The test is: is there a reasonable suspicion and can further evidence be gathered?” He said if the case had been treated as a murder case, the code for the Crown prosecutor sets out a lower threshold test which can achieve a charge and a remand in custody.

Then, on 17 January, the CPS authorised the charge of perverting the course of justice and Mr Parish became the officer in charge of the case.

 On 27 January 2015 Mr Port was charged and bailed and the investigation into Anthony Walgate’s death then ceased until after Jack Taylor’s body was found. Just continuing with the chronology with Anthony through to the court case, you have these dates on your chronology I think, some of them anyway.

On 23 February Mr Port pleaded guilty to perverting the course of justice at Snaresbrook Crown Court. On 23 March he was sentenced to eight months in prison but he served less than half that sentence. Then China gave you some evidence about what was said at the court hearing to her by Mr O’Donnell. She said she talked to him at court and asked him about getting downloads from Port’s computer which might help to draw the link that Anthony was going there as a client and to prove that Port was lying. She says Mr O’Donnell said to her: “There were only two people who knew what happened that night and one is dead and anyway it is too expensive.” And words to the effect of, “So you need to get over it now”.

She said: “We knew Port was lying that they were meeting as friends and that no money was agreed. We knew that he was lying about Anthony going to the bathroom to take drugs. We knew it was all lies. We asked if they had checked if Port did go to work, and we said, ‘He is as dodgy as fuck, untrustworthy, lying, suspicious’ and to us he had clearly done something Anthony, either intentionally or was responsible for his death.” Kiera Brennan told you that at the court she said we mentioned downloading the laptop on several occasions. We were told it was a very expensive procedure and wasn’t worth spending the money on. That was the impression we were given. We felt they just didn’t try, they thought it was a young boy shagging people for money, that was just the impression I got. In that connection DS O’Donnell agreed that the police ought to have examined the laptop sooner and comprehensively, carried out the PND check, checked work records and investigated the X1 and X3 allegations, as well as carrying out a further interview and that had those things done Port would have been charged with murder, remanded in custody and the lives of three young men might have been saved.

The borough officers all told you that they thought that HAT should have taken on the investigation. Then, as I think I have already reminded you, on 8 April 2015 Mr Kirk advised that Port’s laptop should be downloaded and at that stage that was when Mr O’Donnell tasked Mr Parish to do it.

 It was finally submitted on 28 April, many of the details on the submission application were inaccurate and out of date because they had been cut and pasted from an earlier document.

On 15 July Mr Parish received that USB stick back. He looked at the material and prepared a report dated 15 July 2015, which is at tab 48. As I have already reminded you, that report really didn’t do justice to what was truly on that laptop. He apologised to you for not doing it properly and agreed he should have done.

He said had he found the material which DC Thomas in Lilford found, he would have reported that to DS O’Donnell.

To quote him, he said: “If I had found the material, knowing that Anthony had died while in Port’s flat of an overdose of GHB and knowing X1’s allegations from 31 December 2012 and the X3 incident, it would have posed more questions about Port’s involvement in Anthony’s death. If you put the picture together of the laptop content, X1, X3 and the inconsistencies in Port’s account, then you get a clear picture of someone who is a suspect in a murder.” Despite what you heard from Anthony’s family and friends, the police officers who were asked about it all denied that cost was ever an issue in relation to the laptop examination. It seems it was just not done and that nobody picked it up until 10 months after the HAT advice was originally given and after the murders of Gabriel and Daniel.

Then finally before I leave Anthony and give you a short break, on 24 October 2015, really by pure chance, DC Parish was walking past PC Lindsey McDonald as she was looking at the CCTV from Jack arriving at Barking and meeting up with Port and he recognised Port in that CCTV. That was what Mr Kirk described as a goosebump moment, as people realised that Port was in fact involved in the earlier deaths.

I know we have not been going for very long, but I do think it is important we pause at the end of each chapter to you get a bit of a breather and to collect your thoughts.

We will resume again in 10 minutes, members of the jury. Thank you.

 (2.19 pm)  (A short adjournment)  (2.32 pm)  (In the presence of the jury) THE CORONER: Right, members of the jury, chapter 3. If you would like to turn to tab 11 in your bundles, please, the chronology headed “Gabriel Kovari and Daniel Whitworth”, obviously as we did with the evidence, we are going to look at the investigations into their deaths together. You will appreciate from where I ended off just before the break, that there are some dates which overlap from Anthony’s investigation, which go on to the dates here. I have kept them separate because it seemed too complicated to try and put them all in one document, so that is why you have three separate chronologies, but you will bear in mind that with some of these dates things were happening in the Walgate investigation at the same time. Let’s start with Gabriel. He was born on 17 June 1992. He was quite tall, around six foot, but weighed just over 7 stone, 47 kilos. He and Thierry Amodio, who was the young man you heard from over a TV link from Majorca, he and Gabriel had been in a long-distance relationship for two years before Gabriel decided to come to London to live and work. Gabriel came here in July 2014. Thierry told the police that Gabriel used the name Gabriel Klein on his social media.

On 1 July 2014, so two weeks after he killed Anthony Walgate, Stephen Port gave Ryan Edwards a new phone number. You have that on your chronology here.

On 7 July Chief Superintendent Wilson, who was the recipient of the Ewing email that I dealt with earlier on, took over from Temporary Chief Superintendent Hamer, Mr Hamer being the officer who had dealt with the Anthony Walgate investigation.

John Pape rented a room to Gabriel for six weeks in the summer of 2014. He described Gabriel as an intelligent man who spoke fluent English and who had applied for a job as an interpreter. He said somewhat out of the blue Gabriel announced that he had found somewhere to live in Barking.

 Just pausing there to note that in fact the Operation Lilford investigation discovered that on 18 August, when Gabriel and his friend Karl Kamgdom were discussing through messaging Gabriel moving address, on that day, in fact Port and Daniel Whitworth were conversing on Fitlads for the first time. So there is an overlap there that Lilford uncovered.

Going back to John Pape, he told you that he and Gabriel had a farewell drink together on Thursday, 21 August in a pub on the Isle of Dogs and on 22 August Gabriel left for Barking. You have all those messages at your bundle 51.

On 22 August, Gabriel is messaging Karl Kamgdom saying that he is moving out from John Pape’s tomorrow. He also messaged John Pape using a phone number, which it turned out belonged to someone called Cosmos Marcus. It was Mr Pape who was to find out the identity of Mr Marcus after Gabriel’s death, when he contacted the last number that Gabriel had used to message him and found out that was who it belonged to.

 On 23 August — all this is material that Lilford found and the borough did not — Gabriel sent Karl Kamgdom photographs of the inside of Port’s flat and a pin drop showing the address in Cooke Street. So at least at that stage Karl had the details as to where Gabriel was and, if not the exact address, a very close address to where it was. On that day, 23 August, John Pape and Gabriel messaged one another for the last time.

We then come to 24 August. On that day, Ryan Edwards comes back into the picture, because Stephen Port invited Ryan over to meet his new flatmate, who was Gabriel Kovari, and Mr Edwards went. He went with a friend and he met Gabriel and at that visit Mr Port wasn’t there. So it was Gabriel, Ryan Edwards and his friend.

Then on 25 August, as you have recorded here, at 05.51 Gabriel’s phone messaged Karl Kamgdom saying, “I am fine” with a smiley face. I say Gabriel’s phone messaged Karl Kamgdom, because Mr Richards rather doubted whether that really was Gabriel sending that message at that time on that Monday morning.

That certainly was the last use of Gabriel’s phone. Here comes the evidence that I referred to when we were going through the written directions in relation to the date of Gabriel’s death, which you have to resolve. The reason there is something for you to resolve is because of Ryan Edwards’s evidence about it. We have dealt with the 24th, when Ryan went round to Cooke Street to meet Gabriel. There is then a message on the messaging chart which says something like, “Enjoyed meeting Gabriel, why don’t you bring him round to see my girls”, which you will remember Ryan said were his chickens. That is on the very early hours of the 25th and then in evidence to you Ryan Edwards said yes he did indeed, Gabriel did come round on that Monday, to my flat to visit me, which would of course mean he was alive and well on the Monday.

 On the other hand, Mr Edwards was challenged about that because it was before you here, for the first time, that he had mentioned that visit on the Monday. He didn’t refer to it in his witness statements and he didn’t refer to it when he gave evidence at Stephen Port’s trial. That is why there is an issue for you to resolve in relation to that date and that is why you have the brackets in your question 1 in relation to Gabriel and the facts that I have set out on the questionnaire. That is the evidence that you will have to consider in that regard, whether you accept Mr Edwards’s evidence that there was a visit to see him on that Monday or whether you reject it and decide therefore, perhaps, a matter for you, that Gabriel was already dead by that Monday morning.

Also around this date, so mid to late August, Operation Lilford had spoken to Stephen Port’s sister. You may remember Mr Richards telling you about the account that was given by Port’s sister, which was in effect an account about Port having had a dead body in his flat but he had rather conflated the circumstances of the death of that body that he was telling his sister about into a combination of the events relating to known and Gabriel. I suppose the important thing is that the sister had some important evidence to give, which she gave to Operation Lilford, but of course she wasn’t approached during the course of the investigations with which you are concerned.

On 26 August, bottom of this page, on page 1 of the chronology, Mr Port sent Ryan Edwards another new number. In messages which you have in your bundle, at divider 10, Port told Ryan Edwards that Gabriel had “gone to stay with someone”. So he was laying a trail to explain to Ryan that Gabriel had gone somewhere, had left his flat.

27 August, Mrs Denham, you will remember, the lady you heard from in relation to finding two of the bodies, on 27 August at about 5.00 in the evening she went on her usual dog walk and she there was nothing untoward in the churchyard at that time, in other words there was no body there at that time.

But at 9.00 the following morning, 28 August, when she was back in the churchyard, she found the body of Gabriel, a young man described by her as leaning up against a wall, he had dark glasses on, which were skew-whiff — we will come back to those glasses in due course — and she said her first thoughts were that he had had a rough night on drinks or drugs and was sleeping it out, but she said his legs were out straight, possibly one over the other, and she said these words, “He hadn’t just dropped, he was positioned”.

She noticed that he had a big black trolley bag with him and a small black bag, which seemed strange to her, she said there was no body movement whatsoever and, “As he was not prone, as you see a lot, it didn’t seem right to me”. She then phoned 999. She was asked about the documentary that you have heard about a number of times, the BBC documentary, and she agreed that in that documentary she had said this: “He was almost semi-clothed and his clothes were up here towards his chest. It did look highly suspicious. He couldn’t have clothed himself. The whole scenario didn’t look right.” She also agreed that it was possible that she was led in that direction by the media in retrospect, rather than that having been her view at the time. The first officers on the scene were PC Faulkner, who you heard from, and PC Holmes, who you didn’t hear from. PC Faulkner was the young officer, the young uniformed officer, that you heard from. They both approached the body, they noted that his hood was up over his head and they noted that he had what appeared to be blood coming from his nose. He was obviously dead.

On this occasion Inspector Harman was the duty inspector, the duty officer, you will remember I reminded you this morning that he in fact had briefly attended the Walgate scene, which was under the control of Inspector Learmonth, but he had been there briefly. His role in Gabriel’s death was as duty inspector, with exactly the same role which you now are very familiar with and which Inspector Learmonth agreed with in relation to the policies, the building blocks, think murder and the approach to initial response to ensure that everything is preserved. If in doubt, as Mr Harman agreed, it is to be investigated as homicide, unless and until the evidence proves otherwise.

Mr Harman headed straight for the scene at about 9.07 with a female officer called Cooper, they arrived just after 9.20. Mr Harman said that he had only attended about two deaths a year like this, where the scene was unusual and the death was unexpected with no obvious cause. He said that Gabriel did not look like a typical drug user. He said he did adopt the investigative approach and he applied the five building blocks. He preserved the scene and identified forensic opportunities.

An incident management log was commenced, and you have that in your bundle. It set out the plan of action, which was to identify the male, complete checks, establish crime scene, next of kin, CID and SOCO, that’s scenes of crime officer, to be informed. The inspector tasked an officer to walk the grounds and nothing was found. Other officers were tasked to make enquiries about the CCTV. Again there was no relevant CCTV.

Mr Harman did not declare a critical incident, which Mr Learmonth had done, and at page 5 of the document which we have on our screen you will remember he was asked about this passage at the top of the page, critical incident rationale. He said that actually shouldn’t have been completed, because he didn’t declare a critical incident, but it was created by his colleague, PS Cooper. He said: “I didn’t feel I needed to declare a critical incident. I felt I had all the resources I needed and so it wasn’t warranted. Though it was something I kept reviewing.

At 9.25, the London Ambulance Service arrived in the form of Tobie Waggett, the paramedic. He said it was the first time he had seen a dead body in this sort of situation, in a churchyard sat against a wall, and it looked to him as if he had been dead for some hours due to the hypostasis and rigor mortis which he found. He said, “I could see some blood coming from the nose, which is normal at the point of death”.

He verified life as being extinct at 9.27. He said there was no sign of there having been a drug overdose and there were no drugs in the suitcase and no needle marks on the body.

At 9.40 the CID officers arrived — that was Mr Sweetman and Mr Desai — they initiated a search of Gabriel’s body and his possessions and at that stage a wallet was found with Gabriel Kovari’s identification in it. Among his belongings were also an empty bottle of vodka, some toiletries and medication and you will remember the list that Mr Faulkner provided and it was put to him, and he agreed, that Gabriel was obviously someone who cared about his appearance, because there were a number of products within his possession. There was also paperwork with Gabriel’s body which gave John Pape’s address. That was an immediate contact for the police to have with Mr Pape. Again, as with Anthony, there was no phone to be found in Gabriel’s case.

The CID officers, Mr Sweetman and Inspector Harman — well, Mr Sweetman and Inspector Harman, who was a uniformed officer, ruled out any assault or any robbery, because there were valuable possessions on him, and concluded that the death of Gabriel was unexplained but not suspicious. It appeared that neither of them ever asked about whether there was a phone, so they didn’t know about the fact that there was no phone.

In his report at tab 9, if that can be put up on the screen, Mr Sweetman had recorded his view that the deceased had placed himself in that position. But Mr Harman did not agree that he had formed that view. Do you see the last line of the paragraph that we have on the screen now? Mr Harman said, no, I hadn’t formed the view that he had placed himself in that position necessarily. That concludes: “Naturally the coroner will conduct his investigation and we may get the answer from that.” So from that point really it was treated as a coronial investigation rather than a police one and at 14.56 the crime scene was closed.

Pausing there, members of the jury, Ms Mackay said that at that stage, in isolation, in other words in isolation of Anthony’s death, it was not unreasonable to treat the scene of Gabriel’s death as non-suspicious. John Pape, the gentleman with whom Gabriel had initially lodged when he came to the UK, found out that Gabriel had died on 28 August and he got straight in touch with Cosmos Marcus, because that was the last number that Gabriel had used to contact John on, he found out that that is whose phone it was. Cosmos told John that he had driven Gabriel to east London on 22 August.

On the same day Mr Pape spoke to the police, this is at page 13 of the CAD. Mr Pape told the police that Gabriel had come to Barking and that his Facebook account was in the name of Gabriel Klein, that he had no history of depression and was looking forward to his new job, so all that information was provided by Mr Pape to the police on 28 August.

On 30 August Port was sending messages to Ryan Edwards, and Ryan Edwards back to him, about what had happened to Gabriel. You will see in the middle of that page Ryan Edwards sends a message saying, “So it seems like Gab just disappeared? Strange eh?” Port’s response was that was to the effect that Gabriel had mentioned going to Spain, so again trying to bat away Ryan Edwards and detach himself from being connected with Gabriel.

On that same day, we are now on 1 September, Mr Pape contacted Gabriel’s partner Thierry Amodio on Facebook. So there was a link there being made by Mr Pape, and Mr Pape called the coroner’s officer, because he was concerned that Gabriel’s family hadn’t been told that he had died.

I don’t know if we can put up on screen, please, IPC997, which are the messages that Mr Pape provided, if you just go to the next page so you can see an example of them. These are messages between John Pape and Thierry Amodio which didn’t reach the police until 2017, in fact, despite Mr Pape having made it clear back in 2014 that he had this information, the information that was going backwards and forwards between him and Thierry Amodio. That might be an example of a document you might want to see later, but if you do, then simply send me a note and I will sort that out for you.

Still on 1 September, Dr Geraldine Soosay carried out the post mortem, it is an ordinary coronial post mortem, so no police presence, on Gabriel on 1 September. She had received a written briefing, which you have on your screen, and that was her note on it, having carried out the examination she found that Gabriel’s brain was swollen and his lungs were heavy and there were powdery debris in his gastric contents, which to her might indicate an ingestion of drugs. She therefore took samples for toxicological investigation, she said there was very early decomposition of the body, which could happen within a day or so, especially as the body was found in the open air. She completed her report after the toxicology report was available, which was 7 October. Just to note there how quickly in fact it was turned around in the case of Gabriel, so the post mortem on 1 September and the toxicology back and available on 7 October.

Going back in time to 2 September, and feeding in Daniel Whitworth at this stage, on that date, so Gabriel is dead, his body has been found, the post mortem has been carried out and now Stephen Port is back in contact with Daniel Whitworth again, who I reminded you this morning they were first in touch back in August, Stephen and Daniel. That resumed, that contact, on 2 September. 2 September was the time Stephen and Daniel were back in contact since 26 August, so around the time of Gabriel’s death it stops — which perhaps fits in and makes sense — and then continued almost daily from 2 September, contact between Daniel and Stephen, until Daniel gave Stephen his mobile phone number and then they presumably carried on contacting each other via their mobile phones.

4 September, Mr Pape, who was clearly gathering and feeding a lot of information into the police, sent first of all Thierry Amodio a link to the press report about Anthony’s death. He was clearly concerned as to whether there was any link between Anthony’s death and that of Gabriel. He sent that to Thierry, for him to have a look at.

Then on 6 September, PC Faulkner, one of the two officers who had gone to the scene of Gabriel’s death, took Mr Pape’s witness statement. You will remember he did so over the phone, because his senior officer said there was no car, so he couldn’t go to take it in person, but everybody agrees it is a pretty full statement. In fact what happened was Mr Pape added to it, added further detail at the end of the statement about Thierry Amodio and the two black males called Cosmos and Karl, who I have already reminded you about. Then Mr Pape sent it back and it was emailed — but not emailed to the police, it was emailed to the coroner’s officer, so the police it seems, apart from PC Faulkner who had taken it, didn’t know about Mr Pape’s statement or the contents of it. Ms Mackay said about that that the statement, though it was a good one, she agreed, should not actually have been taken over the phone, because you can miss important details and in any event that statement should have given rise to actions to trace all the people and all the phone numbers which Mr Pape had referred to, so Thierry, Cosmos and Karl, and we know what that would have all thrown up had that been done, but, as I repeat, the officers apart from Mr Faulkner don’t appear to have known there was a statement from Mr Pape. Of course Ms Mackay said there should have been liaison with the family, and I am sure you will remember what happened in that regard, and I will come back to that when we get to that stage in the chronology.

PC Faulkner did himself try numerous times to find or contact Cosmos Cupid but without success, so that came to nothing, as far as police were concerned.

From 10 September, as obtained by Operation Lilford, the Lilford investigation obtained, first of all, a message on Gabriel’s Facebook page from Jon Luck — who as we all know was Stephen Port — saying that Jon Luck was sorry about Gabriel’s death. From then on Jon Luck and Thierry Amodio began to exchange messages, and you have those messages behind tab 49 in bundle C, which is the bundle relating to these investigations.

In fact, it was not until 2016 that police identified that Jon Luck was Stephen Port, through the IP address that was being used and through the nature of the messaging, the content, the grammar and the spelling, which all led them to conclude, quite rightly, that Jon Luck was Stephen Port but there are clearly some important messages there between those two which didn’t make it into the enquiry in 2014.

Just as a matter of chronology, on 10 September as I reminded you earlier, that was the day, as it happens, that Anthony Walgate’s toxicology report came in, so we have some tandem matters running side by side in relation to both investigations.

On 11 September there are more messages between Jon Luck and Thierry Amodio referring to Jon Luck meeting Gabriel at the station here in Barking at 11.00.

Then the same day Port is messaging Ryan Edwards to say that Gabriel had died and telling Edwards not to put that on Facebook. You have that detail on 11 September on your chronology.

On 12 September Jon Luck messaged Thierry saying that he and Gabriel had spent two nights together. On 15 September DS Schamberger was asked to act up as an acting detective inspector, but he wasn’t yet involved in these investigations, that was the day he first was asked to act up. He was, as you will remember, Mr Schamberger, not based at Fresh Wharf where the other officers were, but 20 minutes away, at somewhere called Roycraft House and he described to you a number of demanding roles which he held, and he told you that in his view he didn’t really have the time or the experience to take on a role in relation to Gabriel’s investigation, but he said he didn’t tell anyone that because there was no one else to do the job. This is the day that contact between Stephen and Daniel ceased on the Fitlads app, after Daniel gave Port his phone number.

Also on 15 September, Port commenced 11 days of holiday, annual leave, so he wasn’t working for 11 days after this date.

Just reminding you then, before we come to Daniel’s death, two other important dates in the Walgate chronology which fit in here. DS O’Donnell and Tony Kirk, DI Kirk, were reviewing the toxicology results for Anthony on 15 September, and that was when Mr McCarthy asked for a review and the record said, “File to be passed to MIT or HAT for advice”, which never happened. So that is what is going to contemporaneously in relation to the Walgate enquiry. Moving then to Daniel Whitworth, Daniel was born on 22 March 1993. He was five foot nine and of slim build.

He had been in a relationship with Ricky Waumsley for some four years.

However, he had also been, as I have told you, in social media contact with Stephen Port in August 2014. Daniel worked as a chef, which he loved, and would leave very early to go to work. He and Ricky would text each other until he got to work, where I think they said there was no coverage and they would also text each other if they were apart, as you would expect. On 18 September, at 5.45 in the morning, Daniel left for work. That was the last time Ricky saw him. Later in the day Ricky and Daniel were in communication and Daniel told Ricky that he was behind with his work and would be working late. As the evening wore on, Ricky became concerned and was messaging Daniel and noted that his phone was off, which was very unusual. Enquiries as we know from the following day, the 19th, when Ricky reported Daniel missing, also revealed that in fact Daniel had told his work colleagues that he was going to meet some friends in Barking. He didn’t mention Barking to Ricky.

 Around the time when Daniel would have been arriving here in Barking Stephen Port’s social media reports that he revealed in a message to someone that he was going to meet a friend, he told somebody that he was going to meet somebody and that was clearly Daniel. On 19 September Ricky reported Daniel missing to the Kent Police at 1.30 in the afternoon. Daniel was, as you know, treated as a medium-risk missing person. You were referred through Dr van Dellen to the missing person report which described Daniel as being in good spirits, revealed enquiries with his work colleagues that he had said, as I say, he was coming to Barking to meet friends. That same day Jon Luck, in other words Stephen Port, messaged Thierry Amodio saying that the man Gabriel had gone off with, this is in relation to Gabriel, again carrying on the trail, the man Gabriel went off with was a man called Tony Fairy, who in turn had said that he had left with someone called Dan.

This is Port beginning to set up the story of a link between Gabriel and Daniel. That is the first message which mentioned Dan after Port and Daniel had met.

Same day, 19 September, Port deleted his Fitlads account, the same day he was watching the familiar type of pornography that you are familiar with from 8.00 that night. The following morning, at 11.20, Ms Denham was back in the churchyard with her dog when she found the body of Daniel in almost exactly the same spot as she had found Gabriel’s body. She said his chest was uncovered and he had a plastic envelope with a note inside it, she touched his skin and found that he was definitely dead.

She phoned the police and told them she was the same woman who had found another body a few weeks ago and in her call to the police she said, “It is very peculiar that two blokes were found in the same spot”. Ms Mackay said that that should have triggered an immediate search on police intelligence on Barbara Denham’s name, because if that search had been carried out, there would then have been a connection made between Gabriel and Daniel.

Mrs Denham was asked again about something else she said in the documentary, which was this: “This body was placed in exactly the same position, what made him sit in the same position? Anyone would have found it suspicious.” She told you she probably had thought along those lines, but not while she was in the churchyard, once she was home and had thought it all through. She said she didn’t use the word “suspicious” to the police, it came out in the interviews with the media.

At 11.20 the first two police officers arrive, PC Yexley and PC Brown. PC Yexley, I think it was, told you that PC Brown is in fact gay and knew something about GHB. They were the first officers to attend. You will remember there was initial exchange between a drunken man who was on a bench in the churchyard, but before very long he was dismissed as having anything to do with the death of Daniel, so you can forget about him.

At 11.30 Barbara Denham showed the two officers where Daniel’s body was. They noted his position. You have photographs of it as usual. Notably Daniel was covered in a blue sheet. He had a black table mat under his legs and a small brown bottle in his jeans pocket. He was very cold, he was clearly dead and appeared to have been there for some time.

Again, the officers noticed no obvious signs of abuse or injury, though his clothing was very wet and in his left hand was an A4 protective sleeve and inside that was the piece of paper with a handwritten notes on it.

In Daniel’s wallet, which was in his pocket, was his ID and his address in Gravesend.

PC Yexley said that he had attended one or two deaths where the body had been accompanied by a suicide note. The CAD referred to the possibility of GHB and drain cleaner, and PC Yexley said that came from PC Brown, who knew something about it.

On this occasion the duty inspector was Inspector Mark Joyce, I have reminded you this morning that Mr Joyce was actually at the Pacesetter meeting about Anthony. He attended this scene, created a crime scene. Again he was aware of the building blocks and policies and so on, which I don’t repeat now, and he found out that Barbara Denham had found a second body in roughly the same location within a few weeks, which he described as very surprising and unique. He did not however establish exactly how close Gabriel’s body had been to where Daniel’s was found and he agreed he should have done that.

The ambulance service arrived at 11.46 and pronounced life extinct. At around midday Detective Sergeant Turrell arrived with Detective Constable Yinka Adeyemo-Phillips. You will remember DS Turrell was in fact a borough officer CID, who had worked a MIT team for four years in the past.

 She and Ms Adeyemo-Phillips stayed at the scene from around noon to around 1.00, so they were there for a total of an hour. She, DS Turrell, also agreed with the policies in the murder investigation manual and she said her role was to go to the scene, to assess the situation. She said she didn’t seek the advice of the borough DI, because she didn’t have the slightest doubt that the death was suspicious, despite the contents of the note. With hindsight she says she wishes she had called the HAT car.

DS Turrell did not consider the possibility was that the scene had been staged. She didn’t consider the relevant of a note being in a plastic sleeve, because she didn’t know that the note was in a plastic sleeve. She should have known that and had she known that she said it would have struck her as suspicious, because it didn’t look like it was someone who was trying to take their life, it looked like it was somebody who was trying to preserve the note from the elements. She said she didn’t consider the bedsheet, she missed the table mat and she did notice the state of Daniel’s clothing, but she assumed it had been pulled up and down by the London Ambulance Service, although she didn’t ask them whether that is what had happened.

Finally, she said she did agree that the content of the note was a confession of Daniel being responsible for killing someone else, but she said in her view that was not enough to lead her to preserve the scene. Temporary Detective Constable Yinka Adeyemo-Phillips went with Ms Turrell to the Daniel Whitworth scene, you will remember — winding the clock forward — she will also be going to Jack Taylor’s scene the following year.

Detective Constable Adeyemo-Phillips was tasked to check out the CCTV. She said she didn’t know about Gabriel’s death, that was not something that had came to her attention.

At 12.35 it was discovered that Daniel had been reported missing by Ricky. She was asked about the provision for missing person reports and a similar piece of advice in the guidance in relation to missing persons that again you should think murder if in doubt. She said it was Inspector Joyce’s job to decide whether the death was to be treated as suspicious or not. He decided that it was not after, as I have told you, only being at the scene for just over an hour, an hour and 20 minutes in his case, and it was agreed that there was a real possibility that forensic opportunities were lost by closing the scene down.

You will remember, somewhat oddly, Inspector Joyce said he did complete an incident management log the like of which you have seen in the other investigations, but that has never been found and he couldn’t tell you where his log was. Inspector Joyce then gave you reasons why, looking back, he had decided that the death was not to be deleted as suspicious, he gave I think six reasons as his rationale.

 Firstly, there was a comprehensive note.

Secondly, the note referred to the consumption of G and sleeping tablets, which fitted with the finding of the vial, the bottle. He didn’t know that GHB was a date rape drug and he accepted that, had he known that, that might have made the case suspicious. Third reason for not treating it as suspicious was the fact that Daniel had been reported missing and he said he read into that that he had distanced himself from his loved ones by leaving Gravesend and coming to Barking, as a deliberate precursor to taking his life. Fourthly, he said there was no external bruising and then he gave these two reasons for forming the view that he did.

One, the increasing rate of suicide in males under 25.

His sixth reason, that Barking was one of the top antisocial behaviour hotspots in London, attracting a street life culture and a possible overdose at that location would not raise heightened concerns. He was challenged about those views and he accepted that he could have been making assumptions and that there was an element of confirmation bias on his part, in forming an opinion and then looking for support for it. He said that was his view, despite the oddness of the fact that there was a table mat, the fact that the clothing had been pulled up and the trousers pulled down and that Daniel was wrapped in a sheet, but nevertheless he felt able to rule out that someone had placed Daniel there.

Pausing there, Ms Mackay’s view was that the Daniel Whitworth scene should have been treated as suspicious based on the note, because the note indicated that Daniel had committed a homicide. She said a CRIS should have been raised straight away and a HAT car called and they should have taken primacy. Questions should have been asked, such as why was the note in a plastic sleeve? Where was Daniel’s phone? Where was the note written? In addition, Daniel was someone who had been reported missing and enquiries should have been made about how he came to be in Barking with a bedsheet. She said there was no reason to think he was suicidal. He was a missing person from Kent and the borough officers should have looked at the missing person report and seen the information that that contained, which pointed away from suicide.

 At 14.17 on this date, which is still 20 September, so 2.15 in the afternoon, Jon Luck, that’s Stephen Port, is back on Facebook, communicating with Thierry Amodio saying that Gabriel and Dan had been at an orgy in Barking and that Dan was really into drugs. Again, continuing the false trail after Daniel’s death. That afternoon Ricky was informed of Daniel’s death. He was told he had hung himself. It was Mr Slaymaker as the family liaison officer later who told Ricky it was in fact a drugs overdose.

We then come to Sunday 21 September. And page 4 of your chronology and there were entries in what we have seen several times is the night duty overnight book.

The enquiries through the met intelligence had revealed that the Gabriel mentioned in the note was Gabriel Kovari and there was mention of three scenarios, which you have on your screen at the moment. Three possible scenarios.

1, they were having sex in the churchyard when he administered the G and Kovari passed away there and then.

2, Kovari’s body was moved to the churchyard post mortem.

Or, 3, Kovari didn’t die from the extra G shot and passed away in the churchyard from other causes. The HAT team were not contacted overnight, but the decision was made to seek advice from them the following morning, in other words the morning of the 21st. The advice as recorded was to get call data from Daniel’s phone for the time around Gabriel’s death, obviously to show whether Daniel and Gabriel were together on the night of Gabriel’s death, or not. The clothing of both of them to be seized, advice sought from SC&O1 and enquiries conducted to trace the address at which the note said Daniel had administered the extra G shot.

Mr Joyce created a handover note, which he agreed contained some errors in relation to what the supposed suicide note had said, and he said that was because he didn’t have the note with him when he made his note and it was just a mistake, rather than any deliberate misleading or anything like that.

 I just ask you to note at this point, members of the jury, that Mr Slaymaker was able to do MIB, Met Intelligence Bureau, checks on Gabriel Kline very quickly, and he also did phone data checks on Daniel’s phone for the week up to 28 August, to see if there was any contact between Daniel and Gabriel and that showed that there was no contact.

From then on the truth/authenticity of the suicide note should at the very least have been questioned. In fact, the records for that week that the police did get showed nothing more than Daniel going to work regularly and being in regular contact with Ricky.

Temporary Chief Inspector Kirby, not to be confused with Mr Kirk, tasked DS Turrell to contact the HAT car, he did that because he recognised, as other officers did, the discrepancy between where Gabriel’s body was found and where according to the note he had died and what the note said about where he was killed. That was the reasoning behind contacting the HAT car. DS Turrell did just that at 7.45 that morning, Detective Sergeant Denley was the MIT officer from MIT 13. His line manager, as it were, was Detective Chief Inspector Lyons and it was DS Denley who was actively involved here in Barking throughout that day until 3.00 o’clock, giving advice as to what needed to be done. There is a bit of a dispute as to the reason he was called. He understood he was being called because DS Turrell wanted to know whether to keep Daniel’s clothing or to seize Daniel’s clothing. She said, “No, of course I knew I had to seize Daniel’s clothing, it wasn’t just for that reason that I wanted HAT involved”, so there is a bit of a dispute there.

Mr Denley’s advice, at your tab 26 in his HAT return, was as follows. Get the next of kin to look at the handwriting on the note and ascertain if it is Daniel’s and, 2, look into the circumstances of the death and the finding of Gabriel and check there are no unanswered questions. He said what he meant by that was he wanted the investigating team here to start to dig and to be curious and satisfy themselves and him that everything had been done correctly.

In fact the advice to show the note to the family had come from Mr Lyons, it had come from even higher up. He told you my advice was to get the note shown to the family in the first in instance, because that is the quickest way of establishing what the position was, was it his handwriting or wasn’t it his handwriting. Ms Mackay does not disagree with that as being an appropriate approach, what was wrong was how this was done, as you know.

At 10.29 Mr Denley was sent the suicide note by DC Adeyemo-Phillips and he was told that “Gabriel Kline” referred to the note was Gabriel Kovari, but he didn’t actually remember being given that information. DS Turrell then instructed DC Adeyemo-Phillips to verify the handwriting. She didn’t tell her any more than that, save that there was a discussion about the sensitive nature of the note and not showing the whole note and Ms Adeyemo-Phillips said it was agreed that she would show only a small portion of the note, because of the sensitive nature of it.

 As you know, what in fact she did was to email a very small fragment the of the note to Adam Whitworth, and everyone agrees that that was not an appropriate way of going about it. It should have been done in person, and the senior officers say it should have been done with the whole note.

 At 10.30 on this morning, first of all, Ms Adeyemo-Phillips spoke to Adam Whitworth and told him she was going to send a bit of a note to him. She then emailed him the fragment at 10.52 and she told you she believed she then rang Mr Whitworth and “he confirmed that the writing was that of his son”, at 11.02.

Pausing there, it is agreed that was not an appropriate way of going about this exercise. Ms Adeyemo-Phillips remains convinced that that is what Mr Whitworth did, namely to confirm that it was Daniel’s writing, but she agrees she made no note of it, she didn’t ask any questions, like, are you sure? Or anything like that. It wasn’t done in person, which would have shown what sort of state Mr Whitworth was in when he was being asked this question, just after he had been told his son had died and so on and so farther. She did agree that Mr Whitworth asked to see the rest of the note and she did agree that the evidence shows that just after he was said to have confirmed the handwriting to her Mr Whitworth in fact forwarded the fragment of the handwriting to Ricky, and the question is posed: would he have done that if he had been sure it was Daniel’s writing? She went to on to agree that she didn’t ask Mr Whitworth for any examples of Daniel’s handwriting for comparison purposes and she said she wouldn’t do it this way again.

Mr Whitworth, on the other hand, said that he told the officer that he couldn’t confirm it was Daniel’s handwriting and that is why he sent it on to Ricky.

Mandy Whitworth said that Adam said that he couldn’t be sure and it is agreed again that a further failing was to take a statement from Adam about what he really was saying about the handwriting and Ms Adeyemo-Phillips should herself have made a statement dealing what she had been told, rather than just make that entry “he confirmed” and so on.

Nobody was tasked to ask Ricky about the handwriting, and when he in fact was shown the note he said he couldn’t confirm that it was Daniel’s handwriting. There was an entry in one of the records which described the handwriting as “distinctive”, it’s tab 31, page 4. No officer knows where the word “distinctive” in the context of the handwriting came from, it is certainly not suggested that Mr Whitworth said that and no officer has said that they said it, but that is the word that appears in the document. Had there been any doubt about the handwriting being Daniel’s, which of course the Whitworths say there was and Ricky says there was, it would have been possible to get expert analysis of it and you know that in Operation Lilford when they submitted the note for handwriting analysis, within 24 hours it came back as came back as definitively being Stephen Port’s handwriting. I am going to finish this topic and then we will have another break.

DS Denley said he would have done it differently. He would never have approved sending only a fragment of the letter. He should have been done in person and it should have been done in the context of the family being asked about the content, the grammar and the signature of “Daniel PW” and so on and the lack of personal matters in there.

DCI Lyons went even further, he said: “I was not willing to accept that this was a suicide and a manslaughter, we are a murder team and we think murder first. My idea of showing a note was to find out as soon as possible whether it was Daniel’s handwriting or whether it wasn’t or didn’t they know. I was quite shocked when I saw the extract that was sent. That is not my idea of how to get handwriting content checked. It was patently obvious what needed to be done, it should have been the whole note and in person to the parents and to his partner. I cannot see any possible reason for keep the note from the family.” He said had there been any doubt about the handwriting, HAT would have taken over the investigation.

It is now clear, you may think, that failure to deal with that note appropriately led to it being taken at face value. Ms Mackay said the police should have sat down with family and with Ricky, gone through the note, asked whether they thought it was Daniel’s handwriting and why they did or why they didn’t. If there was any doubt, then an expert opinion should have been sought. Members of the jury, we will have a short break there now and then we will do the last bit for today after that.

 Thank you.

(3.23 pm)  (A short adjournment)  (3.40 pm)  (In the presence of the jury)

THE CORONER:

Members of the jury, there was just one other little detail in relation to the handwriting that I perhaps should have reminded you of and I will do that now. You may remember Mr Whitworth was asked about a statement he made in 2015, and that statement contained the sentence, “We did admit that the handwriting looked like Daniel’s”, but as it turned out in fact Mr Whitworth never signed that statement, so he never signed that as being a true statement of the situation, so just in case you recalled that I remind you about it and the circumstances of it. We are still on Sunday, 21 September, on your chronology we are now at 11.09, when Chief Superintendent Wilson emailed Mr Kirby, because he wanted the HAT to be contacted, he said he was nervous that HAT had not been contacted due to the discrepancy between the content of the note and the fact that Gabriel had not died where his body had been found, that is the discrepancy that was referred to several times in a number of the documents.

At 11.42 Mr Kirby replied to Mr Wilson, confirming that the HAT car had been contacted and agreeing that the discrepancy was rather odd. Going back to the HAT advice, DS Denley had identified some further actions which are at tab 26, page 3. He had identified phone work again, which of course did not depend on the police having the handset, you can do the phone work without a handset, because that could give a loose location where Gabriel and Daniel were on 28 August and help to locate where Gabriel died. That data could also identify associates of each of them. And of course if the work had been done, and it had been discovered that the phones were not cell siting together on 28 August, then that would obviously have cast doubt on the authenticity of the note.

Mr Denley agreed that that work, had it been done, would have revealed a gold mine of evidence. He added as well that an interview for Ricky Waumsley should be considered about his knowledge of Daniel’s friends, locations attended, social media usage, including use of Grindr and other sites for example. He said it seemed to me, Mr Denley, “… that Ricky Waumsley was a potentially very important witness”.

He said: “I spent the course of seven hours that day discussing the matter, consulted DCI Lyons on a number of occasions and we decided we would take this forward to a special post mortem, because we were not happy about the circumstances of Daniel’s death.” The conclusion was for the borough to keep primacy so far, until after the special post mortem and after further enquiries had taken place, and for then there to be further discussion he concluded: “The crux of my advice is to gather all known information about Gabriel and the finding of his body.” He said: “I did advise DS Turrell that the clothing and the bedsheet in which Daniel was found should be retained and sent for analysis.” He described it as “routine day 1 stuff”.

It was in fact Mr Lyons who authorised the special post mortem and he told you: “We flagged up that this was possibly a manslaughter suicide and that even if the note was true and the killer dead, then MIT could take the case but the decision about primacy would be a decision for chief Superintendent Sweeney, not for me.” Said Mr Lyons.

Temporary Detective Constable Adeyemo-Phillips also spoke to John Pape, and John Pape put her in touch with Thierry Amodio, because she was trying to trace Gabriel’s family. Mr Pape expressed his concern to her about another gay man ending up dead in the same place as Gabriel, which to him, Mr Pape, was suspicious. He said in that context he was worried about his own safety, bearing in mind that these two young gay men had been found, but Ms Adeyemo-Phillips reassured him that it was not murder. John Pape and Thierry Amodio were in touch again and Thierry was passing on all the information he was getting from Jon Luck, and you have all that behind divider 49 in your bundle C.

At 5.10 that afternoon Ms Adeyemo-Phillips actually spoke to Thierry Amodio. Mr Amodio gave her a lot of important information. He gave her Gabriel’s family’s contact details. He gave her the detail that a friend of Gabriel was called Jon Luck, who had mentioned a special party in Barking, which Gabriel had gone to with somebody called Tony Fairy and a friend called Dan. This is all the stuff that Amodio was telling Adeyemo-Phillips. And that Gabriel had been to Jon Luck’s flat on 26 August. But no statement was taken from Mr Amodio, the police did not obtain the summary of Facebook Messenger conversation from him that he had. Had they done so, the significance of the timing of the first mention of Dan would or should have been appreciated, namely on 19 September, as well as Jon Luck’s link to Gabriel and the reference to drugs at a party, but no statement as I say was taken and they didn’t take the summary of Facebook Messenger conversation from him.

At 17.23, on the same day, Mr Amodio forwarded to Ms Adeyemo-Phillips Jon Luck’s Facebook page and she sent it to Mr Slaymaker, but no one asked Mr Amodio for copies of the messages until Operation Lilford, and no steps were made to trace Jon Luck, despite the fact that the police knew that he had been with Gabriel prior to his death, from those messages.

Instead, what Ms Adeyemo-Phillips did was to respond to Mr Amodio to say, “Can you ask Jon Luck to contact me?” In other words, asking Mr Amodio to get Mr Luck to contact the police, rather than the police trying to contact him. That was described as “not adequate basic policing”. Every effort should have been made to contact Jon Luck. It could have been done through basic steps. There could have been a message sent via his Facebook page. They could have asked the intelligence unit on the borough to conduct an intel search on the social media sites. Ms Mackay agreed, she said every effort should have been made to trace Jon Luck and even if there was a lack of response to any message put to him on Facebook, that would have been informative, that would have told the police there was something suspicious. All the information provided by John Pape she said should have been followed up.

In relation to page 2, behind tab 28, which was a record by Detective Sergeant Turrell saying that she had tasked Ms Adeyemo-Phillips to do a Met Intelligence Bureau check. She, Ms Adeyemo-Phillips, said she wasn’t asked to do that. That is another example of where one officer says, “I asked so and so to do it” and the other officer says, “Well, I wasn’t asked, so I didn’t do it”. That was on 21 September still.

At 17.50 that day, Ms Adeyemo-Phillips sent a long email to Debbie Turrell, DS Turrell, in which she set out everything that Mr Amodio had told her. There was in that message a wealth of information about Facebook, about Jon Luck who lives in Dagenham. Information about Gabriel meeting someone called Dan. Ms Turrell agreed that that information ought to have struck her as information to build an investigation upon. Yet still no effort was made to take a statement from Mr Amodio, despite the fact that that was the advice that the HAT officer had given.

Instead, DS Turrell explained in her witness statement why she hadn’t taken a statement or had a statement taken from Mr Amodio with these words. She said: “As he resided in Spain, there appeared to be no element of evidential value to obtain a statement.” My record is that those who were asked about that said that was of course nonsense, a statement could clearly have been taken from Mr Amodio and the fact he was in Spain had nothing to do with it at all. That same evening, we are still on Sunday, 21 September, Mr Amodio sent Ms Adeyemo Phillips an email, this time with a link to the Barking and Dagenham Post report of Anthony Walgate’s body being found on Cooke Street, and asking her whether this could be related to Gabriel and Daniel. She said I didn’t relate it to Anthony’s case, so I sent a reply that there was no connection. That is Mr Amodio making a link between the three deaths but being told there was no connection.

I just remind you at this stage, in this stage in these investigations there was no CRIS, there was no computer record in relation to this investigation, which is why nobody really knows who had been tasked to do what or what had been done. Of course, if there had been a CRIS it could have set out what actions there were, what needed to be done and by whom. Finally in relation to 21 September, China Dunning spoke to the family liaison officer Mr Slaymaker that day and his note agrees with what she says she said, which is that Anthony would not have taken GHB of his own accord.

We move then to Monday, 22 September. Chief Superintendent Wilson told you that he remained concerned about the coincidences between the deaths of Gabriel and Daniel, that they were found at the same location, in very similar positions, leaning against the same wall, by the same member of the public and that the apparent suicide note in which Daniel confessed to killing a male, who by then they had identified as Gabriel Kovari. He, Mr Wilson, said he wanted SC&O1 to take primacy because Gabriel did not die in the churchyard, and he asked DI Kirk to liaise with homicide command.

He, Mr Wilson, planned a gold group for 4.00 that afternoon. He appointed A/DI Schamberger to oversee the investigation, so that is when Mr Schamberger took over, 22 September. DS Turrell as officer in the case and SC&O1 “to support in an advisory capacity”. At 8.35 that morning Mr Kirk sent Mr Schamberger Mr Sweetman’s assessment of the Gabriel Kovari scene. Mr Schamberger said he wasn’t sure if he read that.

At 9.40 Mr Schamberger and Ms Turrell went to Fresh Wharf police station for a briefing by DI Kirk. They were told at that briefing to get the cell site and call data, which all agreed was a quick and easy exercise, and they were told to research Grindr and Bender, to search Daniel’s home and seize his computers, phones and diaries and to enquire with the crime scene manager about whether Gabriel had been moved and the note concludes “Open source”, meaning open source intelligence enquiries and CCTV, being actions that were tasked at that briefing.

 At that point SC&O1 refused to take primacy, so Mr Wilson then spoke to a homicide commander, as was the policy, to try to persuade them. He was not sure who it was, whether it was Mr Sweeney or somebody else, but he tried to persuade them but they still refused to take primacy and he chose then not to take it any further, something which he now regrets, he said.

Mr Wilson also said he regrets not recording his conversation with that commander and overall Mr Wilson concluded by apologising to the families for the substandard work done in the borough.

At 11.13 on the 22nd DS Turrell emails tasks to her team. You will remember that the suggestion was this wasn’t really an appropriate means of doing this. It should all have been on a CRIS, so everybody knew what task was what. She appointed in this email Jackie Baxter, DC Baxter, to act as the family liaison officer for Kovari and Paul Slaymaker for Daniel Whitworth’s family.

Mr Slaymaker was to search Daniel Whitworth’s address and seize the items that I have just listed and look for any drugs.

Debbie Turrell, DS Turrell, said she was not aware of what was and was not done as a result of this email, but she should have been, she said.

 I will remind you again in a moment, but you will remember, that DC Baxter did not contact Gabriel Kovari’s family.

At 4.00 that afternoon was the gold group. The original intention had been that senior HAT officers would attend. Mr Lyons said he was invited far too late to be able to attend that meeting. Again, there is a record of that meeting, again reference to cell data and cell site phone data to be obtained. In fact this says it is to be obtained by DI Kirk, but he said it wasn’t his job to get that done. Mr Schamberger was supposed to arrange for the officer in the case, who was DS Turrell, to gather intelligence packages for Gabriel and Daniel. DS Turrell asked Mr Slaymaker to get data on Daniel’s and Gabriel’s phone, but nothing was ever done on Gabriel’s phone and they never applied for data in relation to Daniel’s phone for the wider dates, although that had been tasked.

At this stage Mr Slaymaker agreed when he gave evidence that it was a deeply unsatisfactory way to investigate these two deaths. There should have been a PIP3 accredited officer overseeing it. He said, “I didn’t make any link with Anthony Walgate’s death”. He agreed that the suicide note, as it was called, raised many questions which were best answered by a MIT team, who were better placed to pull all the strands together. Superintendent Wilson said that after the gold group he spoke to DI Kirk about “forensicating the note”, but nothing was done about that.

 DCI Lyons agreed that primacy would have been taken if his team had known that Daniel was with Ricky on the night that Gabriel died, which of course is what Ricky had said in his statement, that he was pretty certain about, and which, winding again the clock forward, you will remember that when further enquiries were made with Daniel’s family, the Whitworth family recalled they had all had a family get together that weekend and indeed that they had all seen Daniel and he had been absolutely fine, which he wouldn’t have been if he had been responsible for killing Gabriel at the end of August, or days before that family get together.

Just reminding you again, DCI Lyons agreed that primacy would have been taken if they had known that Daniel was with Ricky on the night that Gabriel died.

I just pose the question for you to consider, is it as simple as that, because you may think the borough could easily have found that out from Ricky and Ricky’s phone records, which we will come back to, because they gave some further detail about that.

Mr Kirk agreed again that this should have been an SC&O1 investigation. He agreed that after primacy was not taken his task was to try to explain the deaths through his officers and if they became more suspicious, to refer back to SC&O1. Mr Schamberger told you that the borough officers were simply not working in a safe environment and couldn’t give each case the attention it deserved.

At 11.20 on the 22nd Mr Kirk sent Mr Schamberger the HAT return. Mr Schamberger was not sure if he read that either. His understanding, Mr Schamberger’s understanding, was that the handwriting had been compared and verified as he put it, and he believed that the investigation was being run by DS Turrell and by her team.

There is then a record from DC Adeyemo-Phillips saying that the phone work was being done, but, as you know, it wasn’t. If it had, the cell site analysis would have shown Daniel’s phone in Gravesend at the time of Gabriel’s death, and of course that would have cast serious doubts — well, it would have established that he wasn’t in the graveyard with Gabriel.

Between 13.30 and 13.50 on 22 September police searched Daniel and Ricky’s flat. They seized an address book and they seized what was described as a handwriting sample which was a list, I don’t know if you remember it, it is your bundle, a list of things in capitals, which you may think was not a very good piece of handwriting sample to compare, but anyway it wasn’t compared with the note in any event.

It was pointed out that when Mr Slaymaker went to carry out that search he could have taken the note with him and shown it to Ricky, but that wasn’t done. In fact, as you know, Ricky didn’t ever see the note until the inquest, which all agree was another failure. The Whitworths say that they were told that the note would be submitted for expert analysis, “So that you will know one way or the other”, but Mr Slaymaker says he didn’t say that and it had been left with Adam Whitworth to decide whether to show the note to Ricky.

Mr Slaymaker was tasked to continue the phone work on Daniel’s phone going back to at least 28 August for connections with Kovari and cell site, as the note recorded, and he was also asked if he could get this done for Gabriel’s phone, which again I have told you was never done. All of that was set out in an email into which Mr Schamberger was not copied when he should have been. There should have been a CRIS, as I say, which anyone could set up but nobody did. Finally in relation to that day, DC Baxter’s role was twofold.

Firstly, her role was to contact the family as soon as possible and provide them with information. Secondly, as family liaison officer, to obtain relevant information from the family about why Gabriel was in the UK and how he ended up dead in Barking. DC Baxter did neither of those things, and nor did she look at the HAT advice, nor the assessment of the scene by DS Sweetman. Emails were sent to her by the coroner’s officer on 28 October, to which she did not respond, and on 15 April she was asked for a background statement, which she did not obtain. She put her “fundamental failures”, as they were put to her, down to her being very busy.

Tuesday, 23 September that morning DS Turrell set out some further actions which needed to be completed. Ms Adeyemo-Phillips was tasked to get CCTV and to look at the timeframe between 19.30 the night before Daniel was found and 19.30 the night before Gabriel’s death, but that was not done.

DC Baxter was tasked to take a statement from John Pape, and in fact we know that had already been done by PC Faulkner on 8 September. So no further statement in fact was taken from Mr Pape. Mr Slaymaker was to take a witness statement from Daniel’s employer and from Ricky Waumsley. A statement was taken from Daniel’s colleague, which revealed that he had headed off to Barking on 18 September after work.

That was a detail that was already in fact recorded on the missing person report. Enquiries were made with HR at Daniel’s place of work, but there was never a statement taken from his employer.

Between 11.35 and 13.55 on that date was the special post mortem carried out on Daniel’s body by Dr Swift. His briefing before that post mortem was the HAT return, which you have seen. DS Denley and DI Schamberger and others were present and the notes were made by a crime scene manager called Gallagher. The strategy at that special post mortem was to ascertain the cause of Daniel’s death. Was it consistent with the note? To identify any sign of possible assault or third party involvement and to try to identify the male who the deceased had described as “having sex with the previous evening”. Those were the police aims which were briefed to Dr Swift before the post mortem.

Upon his examination he found no cause of death, so he too, like the others, referred samples for toxicology. He did make relevant findings though for which he can now give a probable cause. He found bruising, which was very likely to have been caused in life, to the armpits and chest of Daniel, which was consistent with the carrying of the body or manhandling by holding him under his arms, but not in his view consistent with rough sex. He also found petechiae and bruising to the neck, Dr Swift was sure that he told the police to get the blue bedsheet tested.

We know that after the post mortem, or certainly in Dr Swift’s absence, the police with DS Denley discussed whether the bruising might have been caused during rough sex, but Dr Swift was never asked his view about that and he told you he didn’t think that was how it was caused. There was no mention in the post post mortem briefing of the bedsheet recommendation, which again was a failure, although Mr Schamberger says he doesn’t remember that recommendation being made at the post mortem, and at some point he was out of the room, so perhaps he didn’t hear it, was what he said about that. DS Denley thought that the borough officers were capable and he was quite happy to give further assistance and resources if asked for, but it was declined, he said, I wasn’t asked, they didn’t ask me. He said: “If they had been struggling they should have contacted me and ask for help, but they didn’t. I expected them to carry out a basic investigation, including examination of Daniel’s clothing and the bedsheet. The investigation should have included identifying who Daniel had been with the night before, as that was the last person to have seen the victim and is very important evidence.” He, Mr Denley, said: “I discussed the matter with A/DI Schamberger and he is aware further investigation is required [this is what Mr Denley recorded] his current focus is on CCTV, phones, witnesses and associates.” DS Denley said: “I was entitled to expect what has been called professional curiosity of the borough officers.” He agreed that his HAT advice did not record all the advice, it didn’t mention the sheet or submitting the clothing. He said that was possibly a mistake, bearing in mind that others wouldn’t therefore later know about that when they read his HAT return. He said the themes however were included and the additional actions were, he thought, obvious. He said he did not follow up the actions that he had set to see if they had been done, because Mr Schamberger was making notes and he thought, as I repeat, that they were all obvious and they would be carried out.

The HAT advice after the special post mortem was that primacy for the investigation remains with the borough, but SC&O1 and MIT 13 remain a point of contact for them for assistance and advice. Mr Denley has recorded: “A/DI Schamberger agrees with and understands the rationale.” As I have just said, Mr Schamberger did not have much of a recollection of the discussions at the special post mortem. In particular he didn’t remember discussing the bruising, the sheet and the question of rough sex. He understood though that they needed to get the bottom of Daniel’s last movements and how he came to be where he was, the cause of death and his involvement with Gabriel.

He said, this is Mr Schamberger, he was not in a position to do what he should have done, which was to convene a team, discuss what needed to be done and set the required actions.

 He agreed that there was no forensic strategy meeting, despite him having written down the crime scene manager’s phone number on his 11 Anthony Walgate, the bruising was not properly considered in this investigation. There should have been a forensic review with the crime scene manager within 24 hours and the focus should have been on fast-track submissions of the sex swabs to identify “the guy I had sex with”, which would have taken between two and three weeks, she thought.

On 24 September the CRIS was finally opened at 8.35 that morning. As I have reminded you, failure to do so earlier meant that actions had not been followed up and tasks not completed.

That same day, Dr Swift’s preliminary report came in saying that the cause of death was pending further investigations.

I will just take us to the end of 29 September and then we will pause for today.

On 25 September Mr Schamberger reviewed the CRIS and he set five actions, which are set out on pages 84 to 90 behind tab 46. Those five actions were: CCTV; submission of samples; witness statements from Ricky Waumsley, John Pape and Daniel Whitworth’s work, as I say no one seemed to know that a statement had in fact been taken from John Pape back in early September in which important details were given; fourthly, open source investigation concerning Grindr and Bender and consult CIU, which is the communications investigation unit; and, fifthly, phone work on Gabriel and Daniel’s phones, call data, IMEI and cell site going back to 1 August.

 Those were the actions he set.

Ms Mackay said that the problems relating to the phone work stemmed from inadequate recording by the police of actions and a lack of understanding as to who was responsible for what and, importantly she said, a lack of supervision. The phone work was key to providing a link between Gabriel and Daniel, or a lack thereof, and it simply dropped off the investigation after 12 months.

In fact, DI Schamberger contacted Police Sergeant Denley at HAT asking if Daniel’s body could be released, but he was told it was far too early, since there was still a possibility that they were dealing with two unlawful killings.

Then on 29 September, you will remember, there was what has been described I think as a press interview with DI Kirk. The importance of this is that some sort of link seems to have been made by someone at some point between the deaths of Gabriel and Daniel and that of Anthony, because Mr Kirk is emailing asking someone to get him the details of Anthony because he is going to be asked about that.

You have seen the article that actually arose as a result of that interview in which Mr Kirk describes the deaths as unusual and slightly confusing, because they are not local men and we needed to find a connection with the borough by trawling through phone and internet records, which was a matter of course.

Mr Kirk couldn’t really explain why he had mentioned Anthony. He said, “I certainly didn’t think there was any link between the deaths”. He agreed now that he appreciates that there were similarities, but he didn’t make the link at the time.

He accepts, this is Mr Kirk, that had he conducted a review the deaths may have been linked. The similarities might have been looked at far more closely and created an opportunity for MIT to take over. Mr Kirk was not aware of John Pape’s statement, he said. Mr Schamberger also agreed that there were potentially plenty of forensic links, information from members of the public, and the similarities between the deaths themselves, which could and should have led police to Stephen Port sooner.

As I have told you, a statement had been taken from Daniel Whitworth’s work colleague, who said that he and the work colleague caught a train together on 18 September and that Daniel was heading for Barking, but no statement was taken from the employer about whether he was at work on the dates in August relevant to Gabriel’s death and Mr Slaymaker agreed that that should have been done.

Members of the jury, I will pause there. It has been a long day for you and I will continue tomorrow morning. I gather you have agreed that we can start at 9.30 tomorrow, for which thank you very much. That is what we will do and I anticipate that you will be retiring and beginning your discussions by about 11.00 tomorrow, all right? Thank you.

 See you tomorrow.

 (4.12 pm) (The inquests adjourned until 9.30 am the following day) 

Friday, 3 December 2021

THE CORONER:

Good morning, members of the jury.

Before we go back to where we were at the end of yesterday, can I just ask you to go behind divider 10, please, of the white bundle and go to page 5, the date is 8 July 2014.

The topic is the issue which has been described as Mr McCarthy stepping back and Mr O’Donnell replacing him as the senior investigating officer in relation to the Anthony Walgate investigation.

I have already reminded you that the evidence is that it was not unusual and is not unusual for an unexplained death to be investigated or overseen by a detective sergeant, but I just wanted to add a little flesh to that and remind you that Mr McCarthy’s evidence was that he was heavily occupied with other important jobs, including taking on the community safety unit, together with his other onerous responsibilities for example for case progression and that may be relevant to his decision to, what has been called stepping back. I just wanted to add that flesh to that particular piece of the jigsaw.

Right, could we now move back to 30 September, at tab 11, and page 6. This was the day that Mr and Mrs Whitworth and Ricky came here to Barking, first of all to see where Daniel’s body had been found, but also to discuss the note. You will remember the evidence was that Mr Schamberger agreed that the family should visit Barking, including Ricky, but he only authorised that Mr Whitworth should be shown the note. He now agrees that it would have been extremely valuable if the note had been shown to Ricky at that time, and you will remember, winding the clock forward, Ricky didn’t see it until the inquest.

They came to Barking, Ricky drove you will remember. Mr Whitworth thought that they brought with them a father’s day card in order for the handwriting of Daniel to be compared with the note. As you know, Ricky was excluded from the meeting, he was not shown the note, despite the fact that Mr Whitworth was suggesting that it should be shown to Ricky that day. The evidence from Mr and Mrs Whitworth was that they were left with the impression that expert handwriting evidence was going to be sought and they say they were told by Mr Slaymaker that we would then “know one way or the other”.

Mr Slaymaker disputes that he told the family that, he says that he doesn’t recall any discussion about expert handwriting evidence. He does however recall that the Whitworths were saying having seen the note that it wasn’t very personal and he agreed with them about that, that there weren’t personal details in the note.

On that occasion, the Whitworths were not asked about events of the weekend of the dates, 27 and 28 August, the night that Gabriel’s body was found.

They were not asked about that. They told you, had they been asked about that, they would have recalled that in fact there was a family get together that weekend which Daniel was at and he was completely his normal self and, secondly, that they couldn’t think of any time around the end of August when Daniel was missing or that people didn’t know where he was, but neither of those pieces of information were obtained from them at that stage.

After that meeting, and after they had driven back home, Mandy Whitworth told you that she then told Ricky what was in the note. She wasn’t given a copy of it but she had made some notes of what was in it and Ricky couldn’t believe that Daniel could possibly have been responsible for somebody’s death, particularly as he had been behaving so normally at around that time and indeed since that time.

Going back to then your chronology, at 1.45 on 30 November, Stephen Port texted Ryan Edwards again with a new telephone number. He then, as Jon Luck, sends messages to Thierry Amodio, you will remember these messages, about the party and also tells Thierry to keep his, Jon Luck’s, name out of it.

This date is not on your chronology, but on 3 October Mr Schamberger is again chasing the actions in relation to phone work and intelligence, including intelligence relating to John Pape, which had still not been Donna.

Just to remind you, I said to you yesterday that there will be overlaps between the dates in the various investigations and at this stage on 6 October is when Mr McCarthy is chasing the HAT referral for Anthony Walgate, so that is going on in the other investigation simultaneously with the dates we are concerned with here.

On 7 October the toxicology report for Gabriel is available. The same day, Mr Slaymaker took the first statement from Ricky. In that statement, Ricky said that Daniel was at home with him on the night of 27 August. Mr Slaymaker did not ask to look at Ricky’s phone. Had he done so, he would have seen that there were texts to and from Daniel and Ricky about Daniel bringing home some cakes for their tea and Ricky remembered that that in fact is what had happened, Daniel had come home with some cakes. That information about the cakes came from Operation Lilford, right on in September 2016, but it was available back in 2014, on Ricky’s phone, had that enquiry been made. Just going back to Gabriel’s toxicology, you will remember that the findings were that he had a very low level of alcohol. He had some methylamphetamine, but not enough to cause his death. His death was caused by a very high dose of GHB, 758 micrograms per millilitre, which is towards the top end of the range in which death has occurred. The range is 27 to 1,030, so 758 was towards the top of that range where death has occurred.

In addition in Gabriel’s case there was a very high level of mephedrone, a drug which is used to stimulate and induce euphoric effects, those two drugs together, ingested in such large amounts, would be fatal, so said Dr Soosay in her final report after the toxicology had been referred to her and that was available, as you know, from 7 October.

On 10 October, DC Berry, who was not a witness you heard from but he did some intelligence checks on Gabriel on the system called IIP.

On 11 October, once DC Baxter finally found out that there was already a statement from John Pape which had been taken, as I told you 6 seek phone data going back to 1 August. But that was never done.

On 13 October Mr Slaymaker emailed Mr Schamberger. He set out the actions that had been completed so far, namely: CCTV; statements taken; enquiries about Daniel’s work, or some enquiries about that; Gabriel’s property; the toxicology target; and the phone work that had been done so far.

But, firstly, the backdated phone work was still not done, backdated to 1 August, and there had been no statement taken from Daniel’s employer. They had the statement from the colleague, you will remember, but they didn’t have one from his employer.

Mr Slaymaker agreed before you that that statement should have been taken and the employer should have been asked whether Daniel was working on 27 and 28 August, the days around Gabriel’s death. For some reason records are no longer available in relation to that, by the time Lilford asked for them they were no longer available.

I have reminded you already that Ricky’s statement made it clear that it was very unlikely that Daniel had anything to do with Gabriel’s death and Mr Schamberger agreed that should have been flagged up, but it wasn’t and it was overlooked.

You can see from the chronology what was done on 14 and 16 October in relation to checks. But then DC Berry signs off the work as having been completed, when the phone work had not in fact been done.

On 17 October Dr Soosay produced her post mortem report and I have told you what her conclusions were. Meanwhile, in the Anthony Walgate investigation, on 18 October, as I told you yesterday, Mr O’Donnell was sending Mr McCarthy an update with a view to submission to HAT, but that never happened. Instead Mr O’Donnell asked Mr Parish to do a report for the CPS, and we dealt with that yesterday.

Back to this investigation, on 20 October Mr Schamberger updates the CRIS, but there is no reference to the phone work. He accepted that that work, that phone work, had fallen off the radar by then. Instead, on 4 November, Mr Schamberger signs off the phone work as having been completed, when in fact nothing had been obtained. He agreed when it was put to him that this was an incredibly inefficient way of working and by signing it off, the phone work was never in fact therefore to be done.

On 17 November Ms Stanworth, the toxicologist, reported on Daniel. The finding that in his case too — this is now the third time – there was a high concentration of GHB in his system. Her report is dated 21 November, but, as you will remember, despite it being available to the police from them, it wasn’t sent to Dr Swift and he had to chase it several times. We then come to two important emails from John Pape to DC Baxter.

 The first of them on 7 December, I wonder if that could be put up on the screen, please, it is our — thank you.

If you look at the bottom one first, this is John Pape to Jacqueline Baxter, raising his concerns, including the information about: “… older men drugging younger men in order to take advantage of them sexually.

“I worry about what is happening to young men in Barking.” You will remember that information came from the communications between Mr Pape and Mr Amodio.

DC Baxter didn’t reply to that email, so Mr Pape followed it up on the 11th. That is an email at the top of this page: “Let me be more blunt: I have heard that Gabriel and the young guy who died in the same churchyard (Daniel?) were present at the same gay chemsex party the weekend before Gabriel died, I have had indirect information about the party and this person described a scenario in which older men drug younger men in order to take advantage of them sexually. Four young men have died of ‘unexplained’ deaths in Barking between 21 June and 22 September, Gabriel being the second, it would be great if I could talk to you …” She didn’t reply to that email either and she agreed she should have put that information onto the system. She said no link had been made with Mr Pape’s information and the note that had been found with Daniel, which was as described another fundamental failure with which she agreed.

No attempt was made by any officer to identify “the guy I was with last night” or “the mate’s place” both referred to in the note, despite Mr Pape’s concerns in these emails. Both Mr Schamberger and other officers agreed that that was potentially of very high significance. As you will remember, in fact, Karl Kamgdom, whose name the police had, could have pinpointed Daniel to Port’s flat and to Cooke Street. Instead, on 22 December 2014, the investigation was closed by DC Berry.

Then on 7 January it was closed by DS Turrell. Then finally on 22 January, closed by Acting Detective Inspector Schamberger.

All those dates being before the pathologist report was available, and Mr Schamberger agreed that it was inappropriate, indeed wrong, for the investigation to have been closed down before the post mortem report had been received.

Mr Schamberger asked about all of this, said he wasn’t aware of any of the concerns raised by Thierry Amodio or by John Pape. He said he should have seen the John Pape emails and a statement should have been taken from him about the party and so on. He agreed that a statement should have been taken from Mr Amodio as well. It is agreed that Ms Turrell’s reasoning, which I reminded you about yesterday, that Mr Amodio was in Spain, was not a reason for not taking a statement from him. He agreed that what John Pape and Mr Amodio had to say was of the first importance in trying to get to the bottom of the case, but instead the investigation was closed down.

The next date is 23 December, which is when the pathology report in relation to Anthony Walgate became available.

I am feeding these in so you know where the cross reference on dates is, in relation to the various investigations. On your Anthony Walgate chronology you have the events of late 2014 and early 2015, which you can cross reference.

On 13 January, Mr Schamberger prepared the closing report for the coroner on Gabriel.

On 8 April you will remember Mr Kirk was again advising that Stephen Port’s laptop should be downloaded.

Then, finally, Dr Swift prepared his report on 17 April in relation to Daniel, which included the strong recommendation that the sheet should be submitted, which he is clear he said to the officers at the post mortem, but even after receiving that report the sheet was not sent. You will remember, had it been sent, it would have revealed Stephen Port’s DNA on it. On 18 April, the coroner sent enquiries to Mr Schamberger about CCTV, the handwriting and the bedsheet and asking for closing reports. In that context Mr Schamberger told you he hadn’t read Dr Swift’s report. He hurriedly prepared the report on Daniel, which is behind divider 60, and which you will remember contained quite a lot of errors, such as reference to work having been done around the phone number and various details which Mr Schamberger accepted were misleading. He said had he read Ricky Waumsley’s statement, he would have seen that there was positive evidence pointing away from Daniel being responsible for Gabriel’s death and he agreed that he had made “a dreadful mistake”.

He agreed that he should not have interpreted the toxicology and formed his own view as to the cause of death. He should not have said that there were “no suspicious marks”, in the light of the bruising, and the handwriting had not been confirmed, as his report said, via diary and family.

He agreed that there was no evidence as per his conclusion of “both having had sexual encounters with other gay men via websites and other parties have not been identified”.

The sex swabs had not been submitted.

In reality, as you know, Mr Pape and Mr Amodio had identified other witnesses — Karl Kamgdom, Tony Fairy, Jon Luck and so on – and Mr Schamberger agreed that this report might or would have misled the coroner as to what the true situation was.

On 28 April the laptop was finally submitted. On 19 June inquests were held into the deaths of Gabriel and Daniel. It was at those inquests that the family first learned that the bedsheet and the bottle had not been tested, nor had they heard about the bruising before.

Mr Pape gave evidence at one of those inquests and he referred the coroner to what he had heard about the orgy and the reference to older men drugging younger men and he expressed to the coroner surprise that there was no contact between Gabriel and Daniel established by the police. He also asked at the inquest whether there was a link with Anthony but was told that there was none. Mr Schamberger agreed that he did not have a grasp of the evidence when he gave evidence at the inquest. He didn’t know that the phone data had not been obtained. He told the coroner that there were no external parties involved when, had the sheet been tested, it would have shown that Stephen Port was involved.

Following the inquest, the family said that they felt that Mr Schamberger had let them down. Ricky felt pushed out and Mr Schamberger agreed that Ricky should have been dealt with as a next of kin. They all felt that they had been ignored when they pointed out that this was murder and that their information and enquiries were not followed up. That included Mr Pape. Mr Slaymaker apologised if they felt that. So no officer had linked Daniel and Gabriel’s deaths with the earlier death of Anthony, and even after the inquest no one thought to send off the sheet, despite the coroner’s queries and despite the open verdicts. It was agreed by the officers that anyone in the team could have done that, sent off the sheet, but nobody did.

In conclusion, in relation to these investigations, Gabriel and Daniel, there were a significant number of admitted failings and missed opportunities.

Firstly, in relation to forensic evidence, I said I would come back to this yesterday, Gabriel’s sunglasses could have been sent off, as could Daniel’s clothing, the neck swab, the sheet and the brown bottle. When those matters were submitted by Operation Lilford, they all came back with having Port’s DNA on them.

Secondly, had open source and social media enquiries been done the falsity of the note would have been exposed and Mr Amodio, Mr Kamgdom and Jon Luck would have been identified or identifiable.

Thirdly, phone data would have shown that Daniel was not in Barking in August.

Fourthly, a proper investigation into the handwriting could have led to the true uncertainty and an expert analysis, which as you will remember when it was done in Operation Lilford came back within 24 hours showing that the handwriting was definitively that of Stephen Port.

Finally, John Pape’s information about Gabriel’s movements and his concerns about the links between the deaths should have been followed up both by DC Baxter and other officers.

Those matters were all put to Mr Schamberger and he agreed that this was a significantly incompetent investigation and said that the above criticisms put to him by Ms Hill were fair. He agreed that if an investigation develops on an early view, there is a danger that the focus is on material which supports that view, in other words confirmation bias. He agreed that his team took the easy option of taking the note at face value and that they failed to follow up lines of enquiry which would have prevented Jack Taylor’s murder. Mr Schamberger agreed that there was bad policing by individual officers which occurred due to the range and the extent of their other responsibilities. DI Kirk came back and gave some further evidence in relation to these enquiries and he agreed the investigation was disjointed, he agreed that the sheet should have been tested, even as late as after the inquests. He also agreed that had he conducted a review, the deaths may have been linked and an opportunity for MIT to take over would have been there and the similarities would have been looked at much more carefully than they were on his watch. There were unanswered questions and the investigations were closed down too quickly. He said the local policing model was not at that time fit for purpose. He, Mr Kirk, did not know about John Pape’s statement. Then on 15 July Mr Parish got the USB back with the detail of what was on Mr Port’s computer and he prepared the report, which he accepted did not reveal the true picture as uncovered by DC Thomas and Operation Lilford.

Ms Mackay, in relation to these investigations, says that she finds it surprising that the link between the three deaths was not made for the following three reasons.

Firstly, Mr Slaymaker was the family liaison officer for both Anthony and Daniel and yet he saw no link or similarities.

Secondly, the locations where the bodies were found were so close together, they all died from GHB and none of them came from Barking.

Thirdly, the reference to the press interview involving Mr Kirk in which he asked for Anthony’s details makes it seem as if some sort of link had been made back then in September, although Mr Kirk said he didn’t in fact see any link.

She said after the inquest Mr Schamberger should have revisited the matter, bearing in mind the unexpected open verdicts.

Between Daniel’s death and that of Jack Taylor Stephen Port attacked five more living victims and there was one more, even after Jack’s death.

Before I move to Jack, I remind you that it was 24 October 2015 that DC Parish identified Stephen Port as being the male with Jack.

Then chapter 4, members of the jury, if you turn over in your bundle to divider 12 you will see the chronology relating to Jack. You will have noted from the questionnaires that we went through yesterday that there are no questions for you to answer in relation to the investigation into Jack’s death. As any failings that there were, thankfully, did not contribute to any further deaths. You have heard about the investigation into Jack’s death, as there are arguably some similarities between the facts and the investigations which may be relevant to your considerations of the earlier investigations and those involved in them. Jack was 25 when he was murdered. He lived at home with his parents and was very close to his two sisters Donna and Jenny. He worked in a bonded warehouse as a warehouse operative and champagne picker. He had aspirations to join the security industry and had recently taken a loan for training in that field. He had had girlfriends, but Donna had had suspicions that he might be gay or bisexual. His routine was to work from Sundays to Thursdays. At the weekends he would see his sisters and friends and was always home for Sunday lunch. You know Stephen Port was in prison between 23 March and 4 June 2015, having been sentenced at Snaresbrook Crown Court for perverting the course of justice.

Mr Richards told you that the first contact that Operation Lilford identified between Jack and Stephen Port was in July 2015, but it was a very, very brief conversation and it came to nothing — a conversation on Grindr. There was then no further contact between Jack and Stephen Port until September.

On Saturday, 12 September Jack went to Donna’s home as usual. He then went for a curry with friends and then on to the Trades Hall working men’s club. He got home at about 1.00 in the morning. He had had a few drinks but was not drunk. He chatted with his dad for a short while and then at about 1.10 told his dad he was going to bed.

The Operation Lilford evidence showed that he went online when he went up to his bedroom, initially searching for information about becoming a registered security guard and how to get a security licence, but then between 2.00 in the morning and 2.45 he was communicating with Stephen Port and they agreed in the end to meet at Barking station. Just before he left, as you will see on the last entry on this first page of the chronology, Jack set up Find My iPhone, before logging off and heading for Barking.

He called a cab at 02.38, it picked him up at 2.43 and at 2.48 the taxi dropped Jack off at Barking station. As you know, the CCTV then tracks them until they go out of sight. It was that CCTV, which after some clearer version of it had been obtained, that DC Parish was to look at in due course but there are further events to remind you of before we get there. The CCTV showed Port and Jack meeting and walking in the direction of Cooke Street from about 2.48 on the Sunday morning, the 13th. There was then no more heard of of Jack, until his body was found 35 hours later.

At 12.50 or thereabouts in the afternoon of 14 September Mr Elmes, a groundskeeper in Barking, found Jack’s body. You have photographs of where he was found and of course you have been there. It is the other side of the wall from where Gabriel and Daniel were found the previous year. Mr Elmes flagged down two park officers, PCs Holder and Taylor, and Inspector O’Donohue attended. There were two searches of Jack, one done by the officers without disturbing him and then one on the inspector’s direction down to skin.

They revealed no injuries, but those officers did find a small brown bottle and a wrap of white powder. You will recall they didn’t find the tourniquet or the wetwipes and they didn’t notice the needle mark, but it was, as you will remember, raining heavily so perhaps that is understandable.

At 2.01 the CID arrived in the form of Ms Adeyemo-Phillips and Detective Sergeant Sweetman. They stayed for about 55 minutes in total. You will remember Mr Sweetman had attended Gabriel’s scene and Ms Adeyemo-Phillips had attended Daniel’s scene. Mr Sweetman in fact mentioned that fact to his colleague, that he had attended a crime scene at the same location a year earlier in August 2014 and she says she told him that she too had attended a crime scene of a death on the other side of the wall. She told you she had not in fact in the intervening period attended the scenes of any other sudden deaths in the intervening 12 months, so no other sudden deaths since Daniel in her case.

She says that she tasked PC Merritt, another of the uniformed officers, to check behind the wall where the body was found in case other property or more particularly Jack’s phone had been discarded and she said she did that because she recalled that no phones had been found on those whose bodies were found in the churchyard in 2014 — that’s Gabriel and Daniel, obviously. In a statement that she made in November 2015 she stated that she had told Detective Sergeant Sweetman that, in other words that there had been no phones, and that she had made a connection between the three deaths due to the location and the lack of phones. Mr Sweetman doesn’t recall that conversation with Ms Adeyemo-Phillips.

At about 5.00 at that afternoon a young female officer called PC Greenaway and two others went to Jack’s home and PC Greenaway just simply announced that he was dead. His parents were naturally devastated. Drugs were mentioned and straight away Mr Taylor said Jack didn’t do drugs. Police officers went to Jack’s bedroom and noted how tidy it was. They took away some of his prescribed medication and left after about half an hour, leaving a card with Sergeant Ben Tanner’s number on it and saying that he, Mr Tanner, would be in touch. In fact the Taylor family heard nothing for 10 days.

Dr Soosay carried out the coronial post mortem on Jack’s body on 16 September. As with the three other deaths, the cause of death could not be ascertained and she sent off samples for toxicology. It was at the post mortem that the tourniquet and antiseptic wipes were found in Jack’s clothing. Dr Soosay did note that Jack’s brain was swollen and his lungs heavy with blood and water, which may be indicators, as you now are well familiar with, of drug overdose. She also noticed what she described as a possible needle mark on the inner right elbow. You will remember that Jack was right handed and the query was raised therefore as to whether he could have injected himself in his right elbow or would have done.

The bottle and the powder that were found with Jack were sent off for toxicology.

After that 10-day delay, and the distress that that had caused the family, Donna Taylor told you that she called the number on the card that had been left, Ben Tanner’s number, and she said it was PC Jon Taylor, so one of the two park officers, who called her back and was apologetic that no one had been in touch. You will remember you have Donna’s notes about what happened and they are behind divider 18 in your bundle, an example of them is on your screen now.

The same day the two parks officers, Jon Taylor and Dean Holder, visited the family. They commented to the family how smartly dressed Jack had been and that he didn’t look like someone who was on drugs. However, as the family interpreted it, the police were convinced that Jack had died from a voluntary overdose and the family felt that they gave up on Jack because of that assumption, that he was a drug taker. Donna was adamant that those two officers did tell them about the red blanket, but none of the police officers recalls the red blanket. You can see it in the photograph that you have. None of the officers recall that.

When she was told or when they were told that Jack’s wallet was found in his left back pocket, Donna pointed out that that was the wrong pocket, because Jack was right handed. To summarise, you know she gave the police a lot of information, having spent hours with her sister Jenny on the internet researching all these matters and you have her notes in which she and Jenny piece things together, found the press reports into the three deaths and worked out the similarities between the deaths, for example on page 4 of her notes, which is on your screen at the moment, all had GHB, no phones for example, around the same area and all those matters that she has listed there, following the investigations that she and her sister Jenny did.

The family were all adamant, as I say, that Jack would not take drugs.

Donna also did some research on the little bottle that was found and found out from her internet searches that GHB was sometimes stored in eyedrop bottles or hotel shampoo bottles and she also found out that it was a date rape drug.

On 25 September, so we are now on page 4 of your chronology, DI Kirk was informed by his junior officers that the Taylor family felt let down, no doubt because of that 10- or 11-day delay when they had heard nothing. He agreed to you that one part of his organisation was at that stage not doing its job. He didn’t know that Mr Tanner had never even met the family, despite his details being the contact that were left on the day of Jack’s death.

On 28 September the sisters were taken to the scene by those two parks officers, Jon Taylor and Dean Holder, here in the Abbey grounds. Donna is convinced that they were led to believe — and the CCTV had shown – that Jack had walked alone into a park area, which of course is not correct. You will see there were a number of queries raised by her about that, but that is not what the CCTV showed.

PC McDonald became involved, Lindsey McDonald, and she made notes of her contacts with the family which you have on your screen now. She records that the family believed his death to be suspicious because Jack did not do drugs.

On 4 October Sergeant Laffan, who had become involved, and Inspector O’Donohue put together a comprehensive briefing note ready for a meeting on Monday the 5th, which you have seen here, and you will remember this, additions made in red by Mr O’Donohue. This was all prepared ready for a briefing on the Monday morning, Monday the 5th, which was to take place with Detective Sergeant Sweetman and DI McSheffrey, because “there were too many unanswered questions”. That meeting took place on 5 October and the senior officers were advised that the male who Jack met would need to be identified, so in other words the male on the CCTV would need to be identified before the HAT team could be contacted. That was the advice that they were given.

Later that day Mr Laffan and Lindsey McDonald visited the family to show them the CCTV, to see if they could identify the male. Mr Laffan conducted a search of Jack’s room and described it as impeccably laid out. You have on the screen Ms McDonald’s notes as to what Donna was saying that day. Donna had mentioned the Abbey ruins on her investigations had thrown up that they were a gay cottaging site and that she was “already asking whether the previous deaths could have been connected to Jack”, but Lindsey McDonald told her there was no reason to believe that they are connected. The families say that they discussed the other deaths with Mr Laffan. Donna Taylor had copied out the press articles, and you will see those in her notes, and she says she gave them to Mr Laffan but he has no recollection of that and he thinks that during these discussions when Donna was drawing police attention to possible links he was upstairs in Jack’s room, because the search of the room took him some time.

Donna says she was saying Jack would not have gone anywhere dirty like the scene of where his body was found, but Mr Laffan didn’t recall her saying that when he was around.

You will remember that there was a syringe found with Jack’s body which was unused and Mr Laffan said he didn’t know that, that it was an unused syringe.

Donna recalls the police saying the death was not suspicious and her words were “they dismissed us and said that they were not connected”. They were told Daniel had committed suicide and Gabriel was homeless. As I have told you, Sergeant Laffan had no recollection of Donna mentioning the possible links with the other boys and says if he had been aware of that, it would have “gone to the top”. If he had seen Donna’s notes relating to the similarities, the same applied. He didn’t recall any mention of GHB as a date rape drug. He would have looked into all of this if he had known about it, as he did with the other enquiries around CCTV, Jack’s wallet, the phone work and Jack’s coat. Pausing there, matters that are in Ms McDonald’s notes were not, it is said, known to Sergeant Laffan and had he known he would have taken further action in relation to those matters.

On 18 September Teresa Steadman, the coroner’s officer, raised the coroner’s concerns about there being similarities between the earlier deaths, and that is the document that is on your screen at the moment. We now have the Taylor family raising concerns about similarities and the coroner and the coroner’s officer. Ms Mackay said to you that that really should have led to an enquiry into the similarities and there was no basis for the repeated assertion by the police officers that there was no link. Once the family found out that Jack had no phone with him when he was found and once they were shown the CCTV, they became convinced that the male he was with had done something to Jack. Ms McDonald noted on 9 October, having seen the CCTV, that Donna said “she was starting to think that maybe he was meeting up with this male for sexual reasons”.

Donna said Jack’s phone, she told the police this, Jack’s phone was always on and he even carried a separate charging case with him so that he never ran out of battery. Donna feels that they gave the police all the information to prove the links, and she feels that her brother should still be here.

Mr Kirk, in relation to the Taylor investigation, said Lindsey McDonald should have told Mr Laffan about the family’s concerns and that more should have been done and that, added to the coroner’s concerns, it would have made a difference. He said: “I should have been told. People were telling officers that there might be a link and officers were closing their minds.” He agreed that the similarities were obvious and that everyone should have sat down in a room and discussed it. He didn’t even know that there was a specialist crime review group to whom he could have gone.

On 7 October 2015 Mr Laffan received the preliminary toxicology results in relation to Jack. Ms Mackay said that that was another – what she called a staging point, at which the links should have been made. CID should have got grip and governance and all four deaths referred back to HAT at that point.

On 8 October queries were raised about the photograph of Jack and whether the position of his hand indicated that he might have been holding his phone and his phone taken from his hand.

On the 9th Donna was shown clearer footage of the CCTV, or stills from the footage, and that is when she raised the question as to whether Jack may have been meeting the male for sexual reasons.

On 12 October the family approved the press release and the press release took place on the 13th. On the same date, the tourniquet and the swabs were submitted for fingerprint examination.

14 October is the date that DC Parish identified Stephen Port from the CCTV as he walked past Lindsey McDonald’s computer. It was, as Mr Kirk described it, a goosebump moment. He, Mr Kirk, immediately convened a meeting of all the officers who had been involved in the four deaths. He called the HAT car and he ensured that four comprehensive files were put together.

HAT officers arrived at 15.15 that afternoon, and there was a two-hour meeting at which the borough officers pointed out that the cases were riddled with suspicious similar circumstances. Nevertheless the HAT decision even at that stage was for the borough to keep the investigation that night, as “we could not prove murder”. That was despite the concerns that were raised by the borough officers, including concerns about confidence and the gay community.

The borough had prepared a full and comprehensive briefing and Mr McSheffrey laid out the evidence documenting the very obvious bases for linking the four deaths and that they were likely to be homicides at the hands of Stephen Port, but still SC&O1 didn’t take primacy that day.

Finally, Mr Kirk gave evidence before you and in his conclusion he concluded by saying that he accepted that things had gone wrong and he remains of the view that HAT, for whom he now works — he is now on the murder investigation teams — should have taken over the first investigation. He said he accepts the deaths were unexplained and he said: “The whole investigation has been a salutary lesson to me and is something I very much keep in mind in my current role.” He says he now always bears in mind the pressures on the borough and this investigation changed a lot of mindsets. Mr Kirk agreed that the approach of local policing should have been better and could have led to the earlier arrest of Stephen Port. These were important borderline homicide cases, they should have been reviewed. There were missed opportunities in the failures to investigate Anthony Walgate’s case properly, to find out Gabriel Kovari’s last movements and Daniel Whitworth’s whereabouts, and he agreed that the family and friends of those who died had important information and that the way they were dealt with was not acceptable. He concluded by saying that he was deeply sorry.

After Jack’s death, and before the arrest of Stephen Port, Stephen Port drugged and raped another young male, described as X9.

Just taking the matter forward on the chronology, you have the details there.

On 18 October Stephen Port was charged with administration of noxious substances and remanded in custody.

On 27 October he was charged with murder. In due course, as a result of Operation Lilford, Port’s DNA was found on the bottle and the tourniquet which had been found with Jack’s body.

That is the end of my summary of the facts, members of the jury.

I am just going to deal finally with the evidence that you heard from Deputy Assistant Commissioner Cundy. He said: “This has been my absolute priority to find out what went wrong, how it could be fixed and how we can improve.” He said: “From the time of Stephen Port’s trial the Metropolitan Police Service has publicly accepted that things went wrong with these investigations. It was clear to me that there were a number of missed opportunities, as well as wider impact. Professional standards were not met.” He said: “I am deeply sorry, personally and on behalf of the Metropolitan Police, that we did not conduct these cases to the standard which the families deserved. It is a matter of personal disappointment to me.” He then set out five areas in which lessons have been learned.

The first was in relation to the quality of the initial death investigations and the professional curiosity, or lack of professional curiosity, of the investigators, including the individual and collective actions. The approach of both local and specialist investigators should have been better and could have led to the earlier arrest of Stephen Port on suspicion of murder.

Secondly, the leadership of the original investigators, including the direction and support for investigators. There should have been more effective direction, leadership, support and resourcing – could have identified and pursued other investigative lines of enquiry. The lack of clear investigative structures and strategies did not lead to any review, despite concerns being raised by the victims’ families, partners, friends and members of the LGBT community.

Thirdly, the interactions between the local policing and the specialist crime investigators, the interaction did not on occasions meet the Metropolitan Police’s expectations. Local officers did not have the willingness or confidence to challenge the views and advice from serious crime command, so that specialist advice and involvement did not always occur when it could or should have.

Fourthly, the awareness and understanding of the use of GHB, chemsex and criminal activity has now been looked into.

Finally, engagement and understanding and working with members from the LGBT+ community. He said although there were independent advisers in 2014, their advice was not sought and they could have helped challenge the belief that the deaths were not linked.

In relation to the first of those areas, he says the force has now been divided into 12 more resilient basic command units, with broader larger teams including intelligence and more local coordination. There is now a closer relationship between local policing and specialist teams.

There are now four specialist geographical crime hubs across London and one of those is in Barking. Primacy is now a softer-edged decision, the new specialist crime command works more collaboratively with the boroughs and more HAT cars are available 24/7. There is now a specialist crime review group.

There is improved intelligence and analytical support with local intelligence teams and increased awareness of the PND’s capabilities. Following the £2.2 billion reduction there was a reduction in police and staff and an increased workload with reduced morale, but he said in the Metropolitan Police Service we did all we could to keep officer numbers high. One of the core elements of policing has always been to manage risk and prioritise.

Acting up and temporary roles were not as extensive in Barking as they were elsewhere, but I can understand, he said, the additional challenge where in a small borough a number of officers are acting up. In relation to these four deaths, they fell into a category of sudden and unexplained. There must now in such cases always be a CRIS equivalent set up and when deciding whether a death is suspicious or not, the direction is to think homicide.

Mr Cundy said that in these investigations there was a lack of professional curiosity, for example in relation to the note, the lack of phones being found and on numerous occasions actions were set which were not followed. He said it is very unusual for there to be such a wide number of individual and collective errors or failures, despite all the failures these tasks were tasks within the skill set of the local officers he said. A lot of things were not followed through which would have identified Stephen Port earlier. It needed clear leadership.

He said here there was a group of officers who time after time did not do their job. It was not about not having the time, there was a need to identify and understand the risk and prioritise the workload accordingly and shuffle around resources. He was asked again about the number of officers who were acting, trainee or temporary and whether it was unusual and could or should have affected the performance of the borough.

He said, firstly, every police officer of whatever rank is an investigator.

Secondly, there are other boroughs with more officers in such roles and it is a routine part of career development, but of course it does mean if people are acting up or in temporary roles, it means even more importantly that there should be good leadership and supervision.

He said the training now given to officers should ensure there is no repeat of this. He said it was astonishing for him to hear some of the things which were not done here and that actions were signed off when they had not been completed and that the Anthony Walgate and Daniel Whitworth investigations were closed down prematurely. He said the new CRIS system will prevent that.

In relation to computer downloads he says there is now a more advanced and efficient system and most of that can be done locally and quickly.

In relation to the way the families were treated, he said it was plain wrong that Anthony Walgate’s father was told that it was his brother who was dead, that Ricky was told that Daniel had hanged himself and that Jack Taylor’s family were just told that Jack was dead by an officer who just blurted it out as she arrived in their house, without even asking them to sit down. He said it was also wrong that Ricky was excluded.

He said it is particularly important to listen to what the families are saying and a family liaison officer is the bridge between the family and the investigators. In relation to leadership, he said review is a very important part of leadership. Donna Taylor’s notes were referred to and he said the review here wasn’t done by the police, it was done by the families and when they tried to engage the police, they were not listened to. The Metropolitan Police Service simply should not have allowed these four deaths to take place within 15 months, so close together, with no officer reviewing or making the links. There should have been a regular review process. He said: “We can now commission an independent review through a specialist crime group.” But you will remember Mr Kirk was asked about that and said he didn’t even know that that review group existed. Mr Cundy in that context said there needs to be more information made available so that officers do know that that facility is available.

He said the facts here called for an internal and an external review and that even with the pressures of work described here, there is still a way to carry out effective supervision. There was a lack of robust leadership and he said I struggle to understand how investigations were closed down when they were.

In relation to primacy, Mr Cundy said he thought that primacy should have been taken in the Daniel Whitworth and Gabriel Kovari cases. He said Anthony’s case is more nuanced but he noted that DCI Jones had said he would have taken it if he had known about the PND information and the incident at Barking station.

He said if primacy is not taken there is still a lot more that could and should have been done to support the borough.

In relation to GHB, he said many of the officers didn’t know what GHB was or that it was a date rape drug, “… we have undertaken a huge amount to raise awareness in that context. The investigators here knew that GHB was involved but they did not show any professional curiosity to find out about it”.

In relation to engagement with the LGBT+ community, he said, “… there has been a significant increase in engagement since 2015. It is to be noted that there was no advice by MIT for the borough to contact the local independent advisory group”. He was then shown the 2007 review into a serial killer of gay men with important geographical links, and he accepted there are similarities in that case to this. He said there was still a failure here to recognise common threads and more focus on determining promiscuity and risk taking, rather than interpreting the true position.

He agreed there are echoes of that 2007 report here. Finally, he considered as a whole the approach of local policing and specialist investigators should have been better and could have led to the earlier arrest of Stephen Port on suspicion of murder.

Ends

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