Tag: Homicide Detection

The Initial Response and Investigation of Sudden and Unexpected Deaths: The Importance of Vulnerability in Decision-Making

Author Paul Williamson | Posted on

Introduction: The Case of Una Crown

In January 2013, 86-year-old Una Crown was found dead in her home. Despite obvious signs of foul play, police ruled her death non-suspicious, failing to secure the scene. A post-mortem later revealed she had been stabbed and set alight to destroy evidence (BBC, 2015a). HM Coroner noted, “Foul play or suspicious circumstances were too readily dismissed” (BBC, 2015b).

This case highlights the dangers of misjudging sudden deaths, errors that can allow killers to evade justice for years. Thankfully, Una’s killer was finally convicted in 2025, but for 12 years, her murder remained unsolved.

Research confirms systemic failures in initial response, increasing the risk of missed homicides (Forensic Science Regulator, 2015). This blog examines why sudden deaths are sometimes misclassified and how vulnerability can influence police decision-making.

Understanding Sudden Death Pathways

Sudden and unexpected deaths follow three primary pathways:

  1. Expected Deaths resulting from known terminal illness, allowing a doctor to issue a Medical Certificate of the Cause of Death (MCCD). This system was exploited by Dr Harold Shipman, who murdered 215 patients over 24 years. The Shipman Inquiry (Secretary of State for the Home Department, 2003) led to the NHS Medical Examiner system to increase oversight.
  2. Unexpected Deaths where a doctor cannot certify a cause of death, and the case goes to HM Coroner. If no foul play is suspected by police, a non-forensic hospital pathologist determines the cause of death.
  3. Suspicious Deaths, where credible suspicion exists, police take primacy, and a Home Office Registered Forensic Pathologist (HORFP) conducts a full forensic post-mortem.

The first attending officer’s pathway assessment is critical and a misjudgement at this stage can let a killer walk free.

Statistics and the Risk of Missed Homicides

In 2024 there were 570 recorded homicide offences in England and Wales (ONS, 2025). Police detection rates consistently sit around 85% (Cook & Tattersall, 2014). But does this reflect the true homicide rate, or are some being missed?

The first critical step in homicide investigations is identifying a crime. Without this, there is no suspect and no prosecution. Yet this responsibility often falls to police response officers, not experienced and highly trained Senior Investigating Officers (SIOs). The Major Crime Investigation Manual (NPCC, 2021) provides guidance, but it is written for SIOs, not first responders, who instead rely on more limited training and Practice Advice (Home Office, 2024).

The statistics paint a concerning picture. Of the 581,000 deaths in England and Wales in 2023, 194,999 were reported to HM Coroners, with 36,855 inquests opened—representing 19% of reported deaths (MoJ, 2024). While most inquests reach a clear conclusion, around 1105 in 2023 (3%) resulted in open-type verdicts. These are used when the cause of death cannot be definitively determined (MoJ, 2024). Ambiguous deaths that end up in these open verdicts are the most vulnerable to misinterpretation when compared to “self-solvers” (Innes, 2003, p.197) where the evidence clearly indicates a crime and the person(s) responsible.

History warns us of this risk of misinterpretation. Johnson (1969) exposed systemic failings, finding 5% of presumed natural deaths were unnatural, including 27 undiscovered homicides. His research showed cognitive bias, poor scene assessments, and overlooked injuries, particularly among elderly and infant deaths.

So, are we deceiving ourselves with the homicide detection rate and are murderers still slipping through the net?

The Critical Nature of Initial Response

The first moments at a sudden death scene are pivotal. The initial attending officer’s decision to classify a death as suspicious or not determines the course of the investigation. A single misjudgement can let a homicide go undetected.

Interestingly, Stelfox (2006) identified three reasons why homicides are misclassified:

  1. Failure to collect evidence effectively.
  2. Failure to interpret information correctly.
  3. Failure of supervisors to challenge flawed assumptions.

Systemic Failures in Initial Death Classifications

Over five decades after Johnson’s (1969) research, the Forensic Science Regulator (2015) examined 32 sudden deaths initially deemed non-suspicious and exposed the same investigative failures:

  • 10 cases transpired to be homicides.
  • 5 additional cases remained suspected murders.
  • Initial police decision-making contributed to 60% of potential missed homicides. Apparent and obvious indicators of suspicion were overlooked and in 5 cases, no body inspection occurred, despite visible injuries being discovered later.

Ultimately, the system worked and these cases were investigated. However, flaws in the initial police response were again exposed, leading the researchers to conclude that there was an ongoing risk of homicides being missed.

Revisiting the “Fatal Call” Concept for 2025

A wrong decision at a sudden death scene can mean justice lost, a concept Jones (2016) termed the “fatal call.”

While forensic advancements like advanced imaging techniques and AI-driven analysis offer new tools, they also introduce the risk that reliance on technology without professional curiosity can reinforce cognitive biases rather than eliminate them.

At the same time, in a drive for efficiency, some forces have shifted initial sudden death classification to paramedics in certain circumstances, significantly altering the process. New protocols reduce police involvement, giving ambulance crews greater decision-making power. While the shift to paramedic-led classification aims to ease demand on police, it raises a concern that it may inadvertently increase the risk of missed suspicious deaths. Paramedics are not trained investigators, and signs of foul play may go unnoticed.

This operational shift represents a change in the investigative landscape that warrants research to assess its impact and ensure that efficiency is not coming at the cost of deaths being misclassified.

This danger of misclassification is real. In 2015, John ‘Goldfinger’ Palmer, who was famously implicated in laundering gold stolen in the Brinks Mat robbery, was found dead in his garden. Paramedics and police classified it as non-suspicious and resulting from recent surgery (Cawley, 2017). Several days later, a standard post-mortem revealed he had been shot six times (BBC Gangster, 2023). The error cost investigators critical time and evidence. Despite a £100,000 reward, his murder remains unsolved.

How many more fatal calls will go unchallenged?

The Role of Vulnerability in Decision-Making

Jones (2016) also found that in all 15 suspicious cases examined by the Forensic Science Regulator (2015), victims were vulnerable due to age, drugs and alcohol use or situational factors such as domestic abuse. Instead of prompting greater scrutiny, these factors often led investigators to prematurely close cases.

This reflects case closure bias, which involves the tendency to close investigations too early, misinterpreting evidence and overlooking alternative explanations. Contributing factors include resource and workload pressures, a desire for quick resolutions, and discomfort with ambiguity.

The Stephen Port Grindr Killer case illustrates the consequences of such bias. Port used Chemsex drugs to sexually assault and murder four young gay men, yet there were failures to link the deaths despite clear similarities. Initial investigations wrongly classified them as non-suspicious drugs overdoses or suicide. A HMICFRS (2022) review criticised the lack of investigative curiosity, reliance on assumptions, unconscious bias, and inexperience, all of which allowed a serial killer to remain undetected for over a year.

If vulnerability leads to flawed decision-making, it must be reframed. Instead of ruling out suspicion, it should be the trigger for investigative scrutiny.

Conclusion: Towards an Open-Mind Approach

Homicide statistics only tell part of the story, they do not account for murders never identified as such. Once a death is classified as non-suspicious, forensic scrutiny is limited, increasing the risk of missed homicides.

Cognitive bias and vulnerability have been shown to influence police decision-making, leading to premature case closures, particularly in deaths involving the elderly, children, drugs, and alcohol.

Investigating sudden deaths requires both professional curiosity and a systematic, evidence-led approach. The goal is not to treat every case as suspicious until proven otherwise, but to eliminate bias that prematurely rules it out.

At UWE Bristol, our training aims to support new officers to be professionally curious, be aware of cognitive and cultural bias and take an evidence-based approach using practical initial response simulations. These reinforce methodical decision-making and the pursuit of all reasonable lines of enquiry. In doing so, we strive to equip new officers with the critical skills and investigative mindset necessary for frontline officers who make the first and most consequential judgment at a scene.

References

Editorial Team

Paul Williamson (Editor-in-Chief); Claudia McCready (Lecturer); Claire Bowers (Senior Lecturer); Eve Smietanko (Joint Programme Leader & Senior Lecturer); Ian Lowe (Senior Lecturer) & Micah Hassell (Senior Lecturer).

If you would like to be a guest blogger, please contact Police.Blog@uwe.ac.uk

Back to top