HM Assistant Coroner Tina Harrington hears the inquest into the deaths of two individuals set alight in Benfleet, Essex

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HM Assistant Coroner Tina Harrington led a five-day Article 2 inquest into the deaths of Kieren Lynch and Jennifer Cronin. The inquest, which commenced on 21 January 2019, revealed that serious failings by Essex Police, namely an under-resourced and inadequately managed police department, had contributed to their deaths.

Background

Kieren was 51 years old and Jennifer, his mother in law, was 72 years old at the time of the incident. Kieren had a history of depression and low mood. His mood deteriorated when his ex-wife, Mrs Lynch, formed a new relationship after their separation. This led to escalating events, resulting in him setting both himself and Jennifer alight on 13 March 2018. Kieren, who was arrested for attempted murder, died on 13 March 2018. Jennifer died later on 30 March 2018.

The Inquest

The inquest heard that the series of incidents started on 11 January 2018 when Kieren drove up to his ex-wife’s property, retrieved a claw hammer and drill from his car boot, and smashed her garden furniture whilst threatening to kill her. Kieren was arrested and charged with criminal damage.

Kieren underwent two mental health assessments, once whilst he was in custody on 11 January 2018 and again on 12 January 2018, following his self-reported suicidal ideations to Essex Police. On both occasions, he was assessed as low risk of suicide, as he had advised of no current or future plans to self-harm.

Despite breaches of bail on 7 and 8 March 2018, no arrest plan was put in place and no attempts were made by Essex Police to arrest Kieren and safeguard his family.

On 12 March 2018, several days after his initial breaches of bail, Kieren continued to harass and threaten Mrs Lynch, their daughter and Jennifer by telephone. The incident was reported to Essex Police, who conducted an unsuccessful search for Kieren. Kieren continued to call the family throughout the night, causing them to fear for their safety. Essex Police initially graded the incident high risk and then downgraded the matter to medium risk the next day, despite the escalating seriousness of events.

On 13 March at 10:15am, Mrs Lynch called 999 and spoke to an officer who advised her to redial 101 and speak to the Force Control Room. The urgency of the matter was disregarded.

Later that morning, Kieren attended Jennifer’s house and set both himself and Jennifer on fire with a 5-litre can of petrol. The source of the ignition was not confirmed; however, a lighter was found at the scene. Kieren and Jennifer both suffered significant burns and were taken to the Burns Unit at Broomfield Hospital. Kieren was noted to have burns on a 96% total body surface area (TBSA) and Jennifer had burns on 33% of her TBSA.

Conclusion

The jury concluded that Kieren’s death was a suicide and Jennifer’s death was an unlawful killing. They delivered a critical narrative, finding that their deaths were as a result of the following contributing factors:

- Inaccuracy and lack of detail in statutory authority databases.

- Information not completed or reviewed in a timely manner.

- Risks posed by Kieren Lynch continually not assessed.

- Arrest attempts not carried out in a timely and efficient manner.

- Lack of efficient cooperation between Police departments and other agencies, through poorly defined areas of responsibilities.

Following the conclusion of the inquest, Tina Harrington issued a Regulation 28 Prevention of Future Deaths report in which she highlighted concerns over:

a) The lack of clarity as to which department is responsible for ‘non- crimed’ events.

b) The lack of liaison between Operation Juno and the Local Police Team in investigating and apprehending Kieren.

c) A failure to accurately record, or record at all, relevant information for the purposes of protecting the Lynch family.

d) A failure to record all potential offences committed by Kieren whilst in breach of bail, which may have led to a lower risk assessment of him.

e) A failure to identify an arrest plan and thereafter a failure to actively pursue Kieren’s arrest.

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