CEDH · CASELAW;JUDGMENTS;GRANDCHAMBER;ENG — 30 mars 2016

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THE UNITED KINGDOM   (Application no. 5878/08)                   JUDGMENT     STRASBOURG   30 March 2016           This judgment is final.   In the case of Armani Da Silva v. the United Kingdom, The European Court of Human Rights, sitting as a Grand Chamber composed of:   Guido Raimondi, President ,   Dean Spielmann,   Işıl Karakaş,   Josep Casadevall,   Luis López Guerra,   Mark Villiger,   Päivi Hirvelä,   George Nicolaou,   Ledi Bianku,   Nebojša Vučinić,   Vincent A. De Gaetano,   Linos-Alexandre Sicilianos,   Paul Mahoney,   Krzysztof Wojtyczek,   Dmitry Dedov,   Branko Lubarda,   Yonko Grozev, judges , and Lawrence Early, Jurisconsult , Having deliberated in private on 10 June 2015 and 20 January 2016, Delivers the following judgment, which was adopted on the last-mentioned date: PROCEDURE 1.     The case originated in an application (no. 5878/08) against the United Kingdom of Great Britain and Northern Ireland lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Brazilian national, Ms   Patricia Armani Da Silva (“the applicant”), on 21 January 2008. 2.     The applicant was represented by Ms H. Wistrich of Birnberg Peirce & Partners, a lawyer practising in London. The United Kingdom Government (“the Government”) were represented by their Agent, Mr   P.   McKell, Foreign and Commonwealth Office. 3.     The applicant complained that the decision not to prosecute any individuals following the fatal shooting of her cousin by police officers was in breach of the procedural aspect of Article 2 of the Convention, which required the authorities to conduct an effective investigation capable of leading to the establishment of the facts, a determination of whether the force used was or was not justified in the circumstances and of identifying and – if appropriate – punishing those responsible. 4.     On 28 September 2010 notice of the application was given to the Government. 5.     On 9 December 2014 a Chamber of the Fourth Section composed of Ineta Ziemele, Päivi Hirvelä, George Nicolaou, Ledi Bianku, Zdravka Kalaydjieva, Paul Mahoney and Krzysztof Wojtyczek, judges, and Françoise Elens-Passos, Section Registrar, relinquished jurisdiction in favour of the Grand Chamber, neither of the parties having objected to relinquishment (Article 30 of the Convention and Rule 72 of the Rules of Court). 6.     The composition of the Grand Chamber was determined according to the provisions of Article 26 §§ 4 and 5 of the Convention and Rule 24. 7.     The applicant and the Government each filed a memorial on the admissibility and merits of the application. 8.     In addition, third-party comments were received from the Equality and Human Rights Commission, which had been granted leave to intervene in the written procedure (Article 36 § 2 of the Convention and Rule 44 § 3). 9.     A hearing took place in public in the Human Rights Building, Strasbourg, on 10 June 2015 (Rule 59 § 3). 10.     There appeared before the Court: (a)     for the Government Mr P. McKell ,   Agent , Ms C. Montgomery QC,   Counsel , Mr J. Edwards ,   Adviser ; (b)     for the applicant Mr H. Southey QC , Ms H. Hill QC ,   Counsel , Mr A. Straw , Ms H. Wistrich, Ms M.Willis Stewart,   Advisers .   11.     The Court heard addresses by Ms Montgomery QC and Mr Southey QC as well as their replies to questions put by Judges Villiger, Pinto de Albuquerque (substitute judge), López Guerra and Spielmann. THE FACTS I.     THE CIRCUMSTANCES OF THE CASE 12.     The applicant was born in 1974 and lives in London. She is the cousin of Jean Charles de Menezes, who was shot dead by police officers on 22 July 2005. A.     Background 13.     On 7 July 2005 four suicide bombers detonated explosions on the London transport network. Three of the suicide bombers were on underground trains and one was on a bus. Fifty-six people, including the four suicide bombers, were killed in the attack and many more were injured. 14.     The Metropolitan Police Service (“the MPS”) initiated a major police investigation to establish the identities of persons involved in or otherwise connected with the explosions. Available intelligence indicated that terrorists were actively planning a further attack within a matter of days, and the threat level posed to the United Kingdom from international terrorism was raised from Level 3 to Level 1. 15.     On 21 July 2005, precisely two weeks after the first bombings, four explosive devices were discovered in rucksacks left on three underground trains and on one bus. As it was feared that the failed bombers would regroup the following morning and attempt to detonate further explosions, the MPS immediately launched an operation to find them (“Operation THESEUS 2”). This operation was led by Police Commander John McDowall as Gold Commander. 16.     At 4.20 a.m. on 22 July 2005, Commander McDowall was informed that intelligence had identified Hussain Osman as a suspect in the failed bombings of 21 July. Both Mr Osman and another suspect were thought to be living in an apartment at 21 Scotia Road, London. B.     Operation THESEUS 2 1.     Commander McDowall’s strategy 17.     At 4.38 a.m. on 22 July 2005, Commander McDowall decided to mount surveillance operations at both Scotia Road and another London address. The overall aim of the operation at 21 Scotia Road was to establish whether the suspects were present in the apartment and to arrest them safely if they came out. Commander McDowall’s strategy for this operation was not recorded; however, it would appear to have been to oversee the premises at Scotia Road through covert surveillance, to follow persons leaving the premises until it was felt safe to challenge them, and then to stop them. In order to implement this strategy, his plan was that a surveillance team from SO12 (Special Branch) should be in attendance at Scotia Road. They were to be supported by a unit from SO19, the Specialist Crime & Operations branch of the MPS. The unit from SO19 consisted of highly trained Special Firearms Officers (“SFOs”) who were usually deployed on pre-planned operations. Although some surveillance officers were armed for their own protection and that of the public, their training did not enable them to be used as a resource to arrest armed suspects. SO19 would normally undertake this task, although armed officers from SO12 could be used for this purpose as a last resort. 18.     The Crown Prosecution Service (“the CPS”) Review Note later found that if Commander McDowall’s strategy had been followed (notably, had the team from SO19 been deployed in time to support the surveillance teams at Scotia Road), events would not have unfolded as they did. 2.     The command structure 19.     Commander McDowall appointed Commander Cressida Dick as the Designated Senior Officer (“the DSO”) in charge, who was to be responsible for accomplishing the THESEUS 2 strategy safely. As such, she had responsibility for the operation at 21 Scotia Road on 22 July 2005. She was based in control room 1600, where she was supported by Trojan 80, an experienced SFO from SO19 who was acting as her tactical adviser. 20.     Detective Chief Inspector C (“DCI C”) was appointed as Silver Commander for the operation at Scotia Road. Although a Silver Commander would usually have ultimate responsibility for the management of an incident and deployment of firearms resources, on this occasion the DSO retained this responsibility and DCI C operated as the DSO’s ground commander. DCI C was supported by and accompanied on the ground by Trojan 84, who, like Trojan 80, was an experienced SFO from SO19 who was acting as a tactical adviser. Trojan 84 was in charge of the SFO team to be deployed and he was in direct contact with Trojan 80. 21.     Detective Superintendent Jon Boutcher (“DS Boutcher”), the Senior Investigating Officer for the investigation into the identity of the persons responsible for the bombings on 7 July 2005, was also appointed as a Silver Commander. 3.     Implementation of Commander McDowall’s strategy 22.     At 5.00 a.m. on 22 July 2005, a surveillance team from SO12 was called out. No request was made at this stage for a unit from SO19. 23.     By 6.04 a.m. two surveillance teams from SO12 had been deployed to the Scotia Road address to oversee the premises and to follow anyone coming out of the apartments. 21 Scotia Road was accessed by the same doorway as 17 Scotia Road and the surveillance teams were stationed in an observation van which had a view of that doorway. 24.     SO13 (the Anti-Terrorist Branch of the MPS) deployed four officers to assist with any arrest and to gain intelligence. DS Boutcher was the link between the control room and SO13. 25.     At 6.50 a.m. Commander McDowall held a briefing during which the firearms strategy was outlined. Trojan 80 was present at the briefing together with the Silver Commanders for the surveillance operations at Scotia Road and the second London address. The DSO arrived at 7.15 a.m.; however, Commander McDowall spoke to her after the briefing to ensure she had all the information and assistance she needed. 26.     As they had not been called out earlier (see paragraph 22 above), SFOs from SO19 were allocated to the operation when they reported for duty. At 7.45 a.m. Trojan 84 briefed the SFOs. The briefing was not recorded, but he appears to have told the team that they “may be required to use unusual tactics because of the situation they were in and that they should think about this”. When asked for clarification, Trojan 84 added that, in relation to a critical shot, the instruction would come directly from the DSO. However, if they were deployed to intercept a subject and there was an opportunity to challenge but the subject was non-compliant, a critical shot could be taken. The CPS later found that this briefing “stoked the [SFOs’] fears that they would meet suicide bombers and that they may have to shoot such people”. 27.     Following the briefing, the unit from SO19 travelled to a police station at Nightingale Lane, which was approximately two miles from Scotia Road. They stopped off for petrol on the way. Upon arrival they received a further briefing from DCI C, which commenced at 8.50 a.m. The briefing was not recorded, but it appears that DCI C confirmed the terrorists had the capacity to attach a device to themselves that would be difficult to detect. He described the individuals involved in the bombings as being “deadly and determined” and “up for it”. The CPS later criticised this briefing as unbalanced, as DCI C had failed to caution the SFOs that not everyone they would stop leaving Scotia Road would be a suicide bomber and that they should not overreact in the heat of the moment. 28.     The team from SO19 was not deployed on the ground until after 9.30   a.m. 4.     Events leading to the death of Mr Jean Charles de Menezes 29.     Jean Charles de Menezes was a Brazilian national who lived at 17   Scotia Road. At 9.33 a.m. he left his apartment building through the common doorway in order to go to work. An officer in the surveillance van saw Mr de Menezes, described him and suggested “it would be worth someone else having a look”. However, as the unit from SO19 had not yet reached Scotia Road it was not possible to stop Mr de Menezes at this stage (as per the strategy outlined at paragraph 17 above). Instead, he was followed by the surveillance officers. 30.     On leaving Scotia Road, Mr de Menezes walked a short distance to a bus stop and got on a bus heading towards Brixton. The CCTV on the bus did not capture the entire journey due to vibrations but Mr de Menezes was recorded as being on the bus by 9.39 a.m. At this point the surveillance team described him as “a good possible likeness” to Hussain Osman. By 9.46   a.m. the description had changed to “not identical”. 31.     At 9.47 a.m. Mr de Menezes got off the bus. He was then seen using his mobile telephone before running back to the bus and reboarding. 32.     There are conflicting accounts of whether a positive identification was made of Mr de Menezes as the suspect at this stage. It appears from the Stockwell One Report of the Independent Police Complaints Commission (“the IPCC” – see paragraphs 45-71 below) that those on the ground had not been able to identify Mr de Menezes as Hussein Osman. The fact that the Surveillance Running Log refers to him at each entry as being an “U/I [unidentified] male” lends some support to this position. Nevertheless, those in control room 1600 appear to have believed that a positive identification of Hussein Osman had been made. 33.     At around the time that Mr de Menezes reboarded the bus, the unit from SO19 began to make its way towards Brixton. The SFO team leader later told the IPCC that he heard over the radio that “it was definitely our man and that he was nervous and twitchy”. 34.     At 9.59 a.m. the surveillance teams were asked to give a percentage indication of the likelihood that Mr de Menezes was the suspect, and they replied that it was “impossible [to do so] but thought that it was [the] suspect”. 35.     Mr de Menezes got off the bus at Stockwell and walked towards Stockwell underground station. There were several surveillance officers in the vicinity and their leader offered to stop Mr de Menezes before he entered the station. The DSO initially ordered that they perform the stop, having been informed that the unit from SO19 was not yet in a position to intervene. However, almost immediately thereafter she was informed that the unit was on hand. As a consequence, she countermanded her original order and instructed the SFOs to stop Mr de Menezes. By this time Mr   de   Menezes was already in the underground station. Trojan 84 relayed the order to the SFOs, informing them that “they want us to stop the subject getting on the tube”. The SFOs were told that they were going to Code Red, which meant that they were to have ultimate control of the situation and that an armed interception was imminent. 36.     The CCTV at the station shows Mr de Menezes entering the station at 10.03 a.m. wearing a thin denim jacket, a T-shirt and denim jeans, walking calmly and not carrying anything. He went down an escalator and onto a platform. There is no CCTV recording of the lower end of the escalator or of the platform: the relevant tapes, when seized by the MPS, were blank. The IPCC Stockwell One Report and the CPS later found that this was because a cable had been damaged during recent refurbishment work. 37.     At 10.05 a.m. a number of SFOs entered Stockwell underground station and ran down the escalators. At 10.06 a.m. they followed Mr   de   Menezes onto the platform. Eyewitness accounts as to what exactly happened next are conflicting, and some of the witnesses gave accounts which, it is now known, could not have been accurate. However, it would appear from the accounts quoted in the IPCC Stockwell One Report that Mr   de Menezes went into the third coach of a stationary train and sat down; one of the surveillance officers shouted to the SFOs that Mr de Menezes was there; Mr de Menezes stood up, arms down; he was pushed back onto his seat and pinned down by two police officers; according to one witness his hand may have moved towards the left hand side of his trouser waistband; and two SFOs (Charlie 2 and Charlie 12) shot Mr de Menezes several times and killed him. 38.     Within days of the shooting, after it had become apparent that Mr   de   Menezes had not been involved in the attempted terror attacks on 21   July, the Commissioner of the Police of the Metropolis, the Prime Minister and the Secretary of State for Foreign and Commonwealth Affairs expressed their profound regret at his death. A representative of the MPS travelled to meet his family in Brazil and apologised directly to them on behalf of the police. An ex gratia payment was agreed upon to ensure that the family’s financial needs were met. They were encouraged to take independent legal advice from a solicitor in the United Kingdom, and they were advised that their legal costs in doing so would be met. C.     Post-death investigations 1.     The initial investigations 39.     The Police Reform Act 2002 and the Police (Complaints and Misconduct) Regulations 2004 required a police shooting to be referred to the IPCC. However, following the shooting of Mr de Menezes, the Commissioner of the Police of the Metropolis wrote to the Home Office to inform it that he had decided not to refer the matter to the IPCC at that time. 40.     As it was not immediately clear that Mr de Menezes had not been connected to the attempted bombings, the Anti-Terrorist Branch initially retained primary control of the scene of the shooting. During this time the Department of Professional Standards (“the DPS”), an independent section of the MPS which had been notified of the shooting at 10.38 a.m. on 22 July 2005, ensured the integrity of the scene, interviewed witnesses, and completed forensic retrieval. 41.     After the shooting, Charlie 2 and Charlie 12 had been taken to a police station. At 2.30 p.m., having taken legal advice, they indicated that they would not be making statements at that time. Instead, they made their statements together at approximately 2.00 p.m. the next day, after they had been told that Mr de Menezes was not connected to the attempted bombings. Some of the details they initially provided have since been either proved false or called into doubt. For example, they initially indicated that Mr de Menezes had been wearing a bulky jacket (CCTV footage showed him wearing a light denim jacket) and that the officers from SO19 had shouted “armed police” when they boarded the train (the IPCC considered such action to be “illogical” when confronting a possible suicide bomber). 42.     An officer from SO12 had seized the surveillance log at 12.35 p.m. on 22 July 2005. However, at 8.40 p.m. the same day, it was handed back to the officers from the unit. Around this time an amendment appears to have been made to an entry; the words “a split second view of his face. I believe it was [the suspect]” appear to have been altered to read “I believe it was NOT [the suspect]”. 43.     At 9.45 p.m. on 22 July 2005, the Anti-Terrorist Branch formally handed over control of the scene to the DPS as they were satisfied that Mr   de Menezes was not connected to the attempted bombings. 44.     On 23 July 2005 a post-mortem examination took place and recorded the cause of death as “multiple gunshot wounds to the head. The cause of death is severe disruption to the brain”. 2.     The first IPCC investigation and the IPCC Stockwell One Report 45.     On 25 July 2005 the DPS formally referred the investigation to the IPCC, whose investigation began on 27 July 2005 when the DPS provided it with the relevant material in its possession. Because of the seriousness of – and the public interest in – the matter, the IPCC determined that it would use its own staff to carry out the investigation. It was overseen by the Chair of the IPCC personally and the investigating team possessed all the powers and privileges of a police constable carrying out an investigation. 46.     The purpose of the investigation was to advise the CPS of any criminal offence that might have been committed; to provide it with the evidence necessary to come to a decision regarding any prosecution; to enable the “responsible authorities” of the officers concerned (the MPS and Metropolitan Police Authority, or “MPA”) to consider what disciplinary or other action they might need to take; to inform the Secretary of State for the Home Department of the circumstances of Mr de Menezes’ death; and to assist the coroner in relation to any inquest. 47.     In particular, the investigation by the IPCC was to examine: (a)     the information that led to the surveillance of the apartments at Scotia Road; (b)     the command structure of the operation, including details of the numbers and types of specialist officers deployed and the tactics available to them; (c)     the qualification and training of those involved and their suitability to carry out their role; (d)     details of the briefing given to the officers involved and any description or photograph of any suspect made available; (e)     whether or not the operation was designated as a “KRATOS” operation (the national strategy for dealing with suspected suicide bombers which permitted the use of lethal force if absolutely necessary) and the policy, operational tactics and authority levels of “KRATOS”; (f)     the details of the mobile surveillance operation from Scotia Road to Stockwell underground station; (g)     the details of police action once Mr de Menezes had reached Stockwell underground station; (h)     whether or not the policy and operational authorities of “KRATOS” were followed and were effective; and (i)     whether “KRATOS” was compliant with Article 2 of the Convention. 48.     The IPCC was also to report on the actions and statements of the DPS from the time of the incident to the formal handover of the investigation to the IPCC to ensure that the IPCC investigation met its obligations under Article 2 of the Convention. 49.     During the course of the investigation, nearly 890 witness statements were taken from police, forensic experts and civilian witnesses, and more than 800 exhibits were collected. The family of Mr de Menezes, together with their legal representatives, were given regular detailed verbal briefings on the progress of the investigation and eventually on its conclusions. 50.     On 30 September 2005 the IPCC investigating team submitted a report to the IPCC indicating, inter alia , that certain officers might have committed criminal or disciplinary offences. The IPCC therefore wrote to the MPS and to the MPA regarding the officers concerned. 51.     On 19 January 2006 the IPCC Stockwell One Report was completed and submitted to the CPS. On 6 and 22 March 2006 the legal representatives of Mr de Menezes were briefed on the IPCC investigation and report. IPCC personnel also offered to travel to Brazil to brief any member of his family residing there. On 14 March 2006 the IPCC submitted its recommendations to the MPS, MPA, Her Majesty’s Inspector of Constabulary and to the Home Office. (a)     Summary of the Stockwell One Report’s conclusions 52.     The report considered all the witness statements and outlined in detail the events of 22 July 2005 and the investigative steps which followed the shooting. In particular it examined the actions and responsibility of the Commanders, their advisers and all the frontline SFOs and surveillance officers. While it accepted that the death of Mr de Menezes was not the result of any deliberate act designed to endanger the life of any innocent third party, it nevertheless concluded that “20.01     [t]here can be no doubt that on the morning of 22 July 2005 a combination of circumstances between 0500 and 1006 led to the killing of an entirely innocent man”. 53.     With regard to this “combination of circumstances”, it identified a number of failings. 54.     Firstly, it criticised the briefings given by DCI C and Trojan 84. “20.8     There is no doubt that the briefings provided by [DCI C and Trojan 84] included a comprehensive update on the intelligence including the links between 7   July and 21 July and the possibility that the firearms officers may have to confront one of the terrorists who had survived the suicide bombings the previous day. What the briefing for [SO19], and indeed the other teams, did not include was any rider about the circumstances in which the Operation KRATOS policy could be used. That policy was only one option available to the Metropolitan Police for dealing with suspected terrorists and suicide bombers. The [SO19] officers were not told that it should only be used as a matter of last resort when they were sure of the identity of the person in relation to whom the policy was to be applied. That should have been included in the briefing.” 55.     Secondly, it criticised the failure to implement Commander McDowall’s strategy by deploying the unit from SO19 to Scotia Road earlier. “20.15     The management of the operation between 07:15hrs and 09:30hrs should have involved giving practical effect to the strategy devised by Commander MCDOWALL so that appropriate resources were in place at SCOTIA ROAD from the earliest possible time. Commander DICK was in charge of the operation following her briefing from Commander MCDOWALL. The policy, which is described at paragraphs 6.3 and 6.4, was, in essence, one of containment, stop and arrest. What occurred between 07:15hrs and 10:06hrs was a failure of that policy. Between 07:15hrs and 09:33hrs there was no adequate effort to put in place police resources at SCOTIA ROAD that would have enabled the Metropolitan Police to give effect to the policy. During those hours there was a series of briefings. None of the eight people who left the flats before Mr DE MENEZES left were stopped in accordance with the strategy and when he left he was simply followed while ineffective attempts were made during the course of half an hour to determine whether he was [the suspect]. If appropriate resources had been in place there would have been the opportunity to stop Mr DE MENEZES during the course of his five minute walk from SCOTIA ROAD before catching the bus in TULSE HILL. ... 20.32     Detective Chief Inspector C, the Silver Commander, was effectively the ground commander with responsibility for SO12, SO13 and [SO19] officers. However owing to the fact that he was still with SO13 and [SO19] at NIGHTINGALE LANE when Mr DE MENEZES left SCOTIA ROAD, and stationary at the T.A. Centre where DE MENEZES was identified as the suspect at BRIXTON, DCI C was always playing ‘Catch up’ in respect of the operation. ... 20.49     ... evidence from the CCTV at STOCKWELL underground station reveals that the [SO19] officers did not enter the station until two minutes after Mr   DE   MENEZES had passed though the ticket barriers. 20.50     While two minutes is a very short time period, the delay in [SO19] getting to the scene and the failure to get a positive identification had enabled a person, believed to be a possible suspect for attempting to detonate a bomb on the underground system the day before, to get on the same bus twice and enter an underground station.” 56.     Thirdly, the report was critical of the delay in handing the investigation to the IPCC. “17.22     The pressures under which the Metropolitan Police were operating following the events of 7 July and 21 July are self-evident. However, the fact that the independent body established by an Act of Parliament to investigate complaints and serious incidents involving the police, and which has independently investigated every fatal police shooting since 1 April 2004, was now to be excluded from the scene, is a major concern for an independent investigation, and should never occur again. 17.23     The fact that there was such concern over the problems with the CCTV tapes at STOCKWELL and the fact that the hard drives on the train were missing highlights the problem. This issue could have been resolved a lot earlier had they been under the control of the IPCC. ... 17.25     The failure to allow the IPCC access has also been highlighted by the fact that the surveillance log 165330 has been altered. ... 17.33     Had the IPCC been involved at the commencement of the investigation, the surveillance log would not have been released for amendments to be made.” 57.     Nevertheless, the IPCC found that high vibrations had interfered with the recording of most of the bus journey, the hard drive on the train had not been replaced on the relevant day, and the recording equipment in the station had been broken during prior refurbishments. Consequently, it concluded that there was “no evidence of a cover-up to withhold this evidence from the investigation”. 58.     Likewise, two expert witnesses who examined the surveillance log could not agree either that it had been altered or, if it had been, who might have altered it. (b)     Prosecutions 59.     The report also identified a number of individuals whom the CPS might consider prosecuting. (i)     Charlie 2 and Charlie 12 60.     As to the shooting of Mr de Menezes after he had been tackled on the train, the IPCC noted as follows. “20.71     The actions of Charlie 2 and Charlie 12 should be considered in light of the day’s events and those of the previous two weeks. At the briefing, they were supplied with a full briefing on the capabilities of the terror suspects. During the operation they had heard the man being followed was being identified as one of the suspects from the previous day’s attempted bombings. On arrival at STOCKWELL, [SO19] went to State Red, authorising a firearms intervention, following an order from the DSO to stop the man from entering the station and tube train. 20.72     They had seen ‘Ivor’ [a surveillance officer from SO12] point at the suspect, who they saw get off his seat. ‘Ivor’ then grabbed the man and forced him back to the seats. Both officers state they believed they had to act immediately to prevent loss of life to the people on the train. ... 20.74     Charlies 2 and 12 clearly believe[d] they were acting in self-defence, and had the right in law to use the force they did. The [CPS] may wish to consider whether the actions of Charlie 2 and Charlie 12 amount to murder in the context of their justification for the shooting of Mr DE MENEZES and having regard to the fact that there were explanations given for the shooting at that time which did not accord with the accounts given 36 hours later. ... 20.94     ... [ The CPS] ... may also wish to consider whether they were grossly negligent to come to the conclusion that they were confronting a suicide bomber. ” (ii)     The DSO 61.     With regard to the role of the DSO, the IPCC stated as follows. “20.77     The order given by Commander DICK was to stop the suspect getting onto the underground station and subsequently the underground train. When interviewed she was asked to explain the word ‘Stop’ and her response was that ‘Stop’ is a common word in policing terms and it was meant as ‘stop and detain’. This opinion is supported by DCI C and Trojan 80 and 84. 20.78     However, the way the order was received by [SO19] must be considered. Following a full briefing, many of the [SO19] officers have described that they believed that they would have to confront a suicide bomber. The [SO19] officers have stated that they believed the man being followed on the bus had been identified as one of the suspects for the failed bombings on 21 July 2005. They had been in a situation of trying to ‘Catch up’ with the surveillance team since their briefing had finished. And as they approached STOCKWELL underground station they hear that the suspect had entered the underground station and they received an order to stop him getting on the underground train. I do not believe that the use of the word ‘Stop’ can be related to normal policing duties. With the mind-set of the [SO19] officers believing that a suicide bomber had entered the underground station, to receive such an order to stop him from DSO cannot be related to normal duties. They had not had the benefit of a rider to their briefing of the sort to which I refer at paragraph 20.8. If they had received such a briefing they might have been more cautious in the way they approached and dealt with Mr DE MENEZES. ... 20.82     I [Senior Investigator J.D. Cummins] comment[s] at paragraph 20.47 on the consequences of the surveillance team having failed to adequately identify the person they were following. However, that team had spent thirty minutes following and staying with Mr DE MENEZES and attempting to identify him. That provided Commander DICK with a thirty minute opportunity to act in accordance with the operation strategy. There was no attempt to do so. 20.83     The SO12 officers who were following Mr DE MENEZES had been authorised to carry firearms for their personal protection and the protection of the public. In the context of the events of 7 July and 21 July when, respectively, there had been a successful detonation and an attempted detonation of bombs on buses it was a failure of the management of the operation to permit Mr DE MENEZES to get on the bus at TULSE HILL. If he had been a suicide bomber that event could have been catastrophic. Therefore the failure to use SO12 to stop him getting back on the bus in BRIXTON is an even more inexplicable failure to apply the strategy. ... 20.87     [The DSO] has endorsed that she was the person in command. The [CPS] may wish to consider whether the manner in which this operation was commanded, the failures to have resources properly deployed and the absence of any other tactical options could be considered to be grossly negligent. ” (iii)     “James” 62.     With regard to the “identification” of Mr de Menezes as the suspect, the IPCC noted: “20.53     ... James [the head of the surveillance teams] did not communicate that some of his team thought that the subject was not [the suspect]. This information should have been fully communicated to [the DSO] as it may have influenced her decision-making. The [CPS] may wish to consider whether this negligence by ‘James’ ... satisfies the test for gross negligence.” (iv)     The other officers on the train 63.     As to any potential offence on the part of the eight officers on board the train: “20.91     Given that they believed they were confronting a suicide bomber it is perhaps illogical that they would have challenged him prior to trying to detain him. The [CPS] may wish to consider whether any of the eight officers on the train who state they shouted or heard the words ‘armed police’ have conspired to pervert the course of justice. ” (v)     Trojan 80, Trojan 84 and DCI C 64.     As the IPCC did not consider that Trojan 80, Trojan 84 and DCI C had been in a position to influence the outcome of events, it was of the opinion that they could not be held responsible. (vi)     The surveillance log 65.     In respect of the possible alteration of the surveillance log (see paragraphs 42 and 56 above), the IPCC did not find sufficient evidence against any individual to suggest that criminal proceedings might be appropriate. (c)     Operational recommendations 66.     The IPCC noted that, in the course of its investigation, grave concerns had been raised regarding the effectiveness of the police response on 22 July 2005. These concerns were not only that an entirely innocent member of the public had been killed in error but also that the police response might not have been adequate to stop a terrorist who was intent on causing harm. It therefore made a number of detailed operational recommendations. 67.     The IPCC pointed out two operational concerns regarding the use of firearms ̶ the substantial delay between the time the unit from SO19 was requested and when it was deployed, and the lack of clarity about the command to “stop” the suspect given the likely mindset of the SFOs. It also made detailed recommendations on command and control issues in firearms operations, including the need to clarify the roles and responsibilities within the chain of command; to establish a clear and common understanding of the circumstances surrounding future operations; and, given the failure to implement Commander McDowall’s strategy to ensure the deployment of the unit from SO19 in time, to put in place better communications channels. 68.     In respect of the surveillance operations, the IPCC expressed concern that the surveillance team, the SFOs, and those in command were not used to working together and were not sufficiently familiar with each other’s working practices; that two surveillance officers believed the person being followed was not the suspect and that this was not communicated to the DSO; and that the surveillance log had been altered. 69.     In relation to the post-incident management, the IPCC repeated its concern regarding the delay in handing the scene and the investigation over to it, and the fact that Charlie 2 and Charlie 12 had been allowed to return to their own base, refresh themselves, confer and write up their notes together. 70.     As regards the communications infrastructure, the IPCC was concerned that key briefings and strategic and tactical decisions were not recorded and, furthermore, that the command and control of the incident was inevitably lost when the unit from SO19 entered the underground. Concerns were also expressed that the existing Firearms Manual and the “KRATOS” policy were patently insufficient to deal with the current terrorist threat. (d)     Publication 71.     The IPCC Stockwell One Report was not made public until 8   November 2007, as publication was delayed pending the criminal trial of the Office of the Commissioner of the Police of the Metropolis (“the OCPM” – see paragraphs 100-01 below). 3.     The second IPCC investigation and the IPCC Stockwell Two Report 72 .     On 14 October 2005 the MPA referred a complaint to the IPCC regarding the MPS’s handling of public statements following the shooting of Mr   de   Menezes. The IPCC carried out a second investigation and the IPCC Stockwell Two Report was published on 2 August 2007. The contents of that report are not directly relevant to the complaint currently before the Court. D.     Disciplinary proceedings against the frontline and surveillance officers 73.     The IPCC had the power to recommend or direct the MPS to bring disciplinary proceedings against individuals. During the IPCC investigation, fifteen officers were served with notices under Regulation 9 of the Police (Conduct) Regulations 2004, informing them that they were being investigated and warning them that the investigation might result in disciplinary proceedings being brought against them. 74.     However, on 11 May 2007 the IPCC decided that no disciplinary action should be pursued against any of the eleven frontline and surveillance officers involved in the operation since there was no realistic prospect of any disciplinary charges being upheld. One surveillance officer received “words of advice” in connection with the alteration of the surveillance log. 75.     A decision concerning disciplinary charges against the two Commanders and their tactical advisers was postponed until after the prosecution of the OCPM (see paragraphs 100-01 below). E.     The first prosecutorial decision 1.     The decision 76.     On receiving the IPCC Stockwell One Report, the CPS considered whether to bring prosecutions against any individual officers for murder, involuntary manslaughter by way of gross negligence (“gross negligence manslaughter”), misconduct in public office, forgery or attempting to pervert the course of justice. It also considered whether to prosecute the OCPM or any individual for offences under the Health and Safety at Work etc. Act 1974 (“the 1974 Act”). In deciding whether or not to prosecute, it first had to apply a threshold evidential test, namely, whether or not there was a realistic prospect of conviction, before asking whether or not prosecution would be in the public interest (see paragraph 163 below). (a)     The first decision letter 77.     By letter dated 17 July 2006, the CPS notified the deceased’s family that the Director of Public Prosecutions (“the DPP”) had decided to prosecute the OCPM, not in the Commissioner’s individual capacity but as an employer of police officers, for failing to provide for the health, safety and welfare of Mr   de   Menezes, contrary to sections 3 and 33 of the 1974 Act (see paragraphs 157-58 below). No individual was to be prosecuted in relation to the death as there was “insufficient evidence to provide a realistic prospect of conviction against any individual police officer”, that is, it was more likely than not that a jury would not convict. 78.     The decision letter, in so far as relevant, provided as follows. “In the circumstances of this case, if the prosecution could prove that [the SFOs] were not acting in self defence (either of themselves or others) then they would be charged with murder. The order was given that Jean Charles was to be stopped from getting on the train. Although officers in the control room intended that Jean Charles should be arrested outside the station, the [SFO team] were not in place to make such an arrest, nor was this intention made explicit to the [SFOs] who were being sent down to the train. All the available evidence suggests that they believed that Jean   Charles had been identified as a suicide bomber, that they had been directed to stop him from blowing up the train and that they had to shoot him to prevent that. ... The burden would be on the prosecution to prove beyond reasonable doubt that these two officers did not honestly and genuinely believe that they were facing a lethal threat and so I looked to see if there was sufficient evidence to disprove that they had such an honest and genuine belief. Both officers stated that Jean Charles was wearing a ‘bulky’ jacket when they saw him but in fact Jean Charles was wearing a simple denim jacket. I therefore took this into account as it could indicate that the officers had lied. However even if I could prove that the officers had lied, rather than simply being mistaken, this alone would not be enough to commence a prosecution for murder as there could be other reasons for an officer to lie. I also considered their explanations of Jean Charles’s movements when they approached him, to see if there was evidence that they had fabricated those accounts to justify their actions. Both refer to Jean Charles getting up and advancing towards them with his hands down by his side before he was tackled by a surveillance officer and forced back into the seat. The [SFOs] then shot Jean Charles. I had to consider whether the prosecution could argue that the restraint meant that no bomb could be detonated and that the firearms officers’ actions were unlawful. However I must bear in mind that this happened in a matter of seconds and there is some independent evidence that supports the officers’ accounts that they feared Jean Charles might detonate a bomb. A witness sitting opposite Jean Charles said ‘I got the impression that he was reaching to the left hand side of his trouser waistband.’ ... As I cannot prove the officers did not act in genuine self-defence, I cannot charge them with murder or any other offence of assault, including manslaughter. There is some disagreement between officers and the members of the public as to whether any warning was given that armed police were approaching the train. In a situation such as this, where a warning to a suspected bomber could be fatal for officers and the public, no warning should be given. However some police officers say that they did hear a call of ‘armed police’ before the shooting and although passengers did hear officers shouting as they ran down the stairs, none of them heard the words ‘armed police.’ Both of the [SFOs] say that they shouted ‘armed police’ immediately before they fired but whether they did, and if so, whether it was intended as a warning to Jean Charles or to others in the carriage is unclear. There is no doubt that some police officers did shout something before any shots were fired .... Unless I could prove that officers had lied ... to mislead any investigation, I could not prosecute them for attempting to pervert the course of justice. Next I carefully examined the roles of those police officers concerned in planning the surveillance and stop and those who carried it out. [T]here were a number of people involved and there is no doubt that messages were misinterpreted with tragic consequences. I have considered whether any errors or other conduct by individuals could be categorised as criminal. In this I have applied the law on gross negligence manslaughter, misconduct in public office and the [1974] Act. Even where I found that individuals had made