Review identifies ‘unacceptable failings’ in police investigation into death of Katie Simpson

Ms Simpson, 21, died six days after being admitted to hospital in Londonderry in 2020 and her death was initially treated as suicide.

Jonathan Creswell, a convicted abuser who was later charged with her rape and murder, was found dead at home on the second day of his criminal trial in April 2024.

The review examined the police handling of the case involving Creswell and identified serious failings in investigative approach, recognition of coercive control, safeguarding practice and oversight.

Dr Jan Melia, the author of the report, said “not one officer thought seriously about abuse/control” in the initial investigation.

“Institutional misogyny reinforces risk, allowing it to be minimised, it dismisses women’s experiences, creating and sustaining a culture where female victims are disbelieved, and perpetrators are given credibility and power,” said Dr Melia.

“This was precisely the case for Katie: not one officer thought seriously about abuse/control, Katie’s lived experience was disregarded, clear warning signs were ignored, established protocols were treated as optional/discretionary, and police chose to privilege Creswell’s account.

“There is an urgent need for trauma-informed training, gender-sensitive risk assessment, and a cultural shift within the PSNI, that challenges and changes its own institutional misogyny, identifying it as a risk factor to victims and the public.”

PSNI Assistant Chief Constable Davy Beck apologised for the “failings in the PSNI’s response to Katie’s death”.

“We remain committed to learning from this case so I welcome the publication of the review which outlines unacceptable failings by the PSNI and indeed by others,” he said.

“From the PSNI perspective we accept and welcome this review and accept the findings in full. We will of course take some time to review the findings in detail and we are committed to working with the author, the Department of Justice and other partners to implement the recommendations in full.

“The review makes clear that we missed opportunities. Warning signs were not fully recognised early enough and we did not listen to some of those who raised early concerns.

“Let me be clear, they got it right and we were too slow to respond to their concerns; that was wrong. Patterns of coercive control were not sufficiently understood or challenged, investigative decisions did not always reflect the level of professional curiosity and rigor that should have been applied.

“The failings are clear, we fell short and for that, I am truly sorry.”

Mr Beck added: “Policing depends on public trust. When we do not meet the standards expected of us, particularly in cases involving vulnerable women and children, domestic abuse and safeguarding, that trust is damaged. It is our responsibility to rebuild it.

“Importantly, work has already commenced and these recommendations will help us shape our continued work to address violence against women and children as we move through years 4 – 7 of the PSNI Violence Against women and Girls action plan.”

He said since this case, it has strengthened training on coercive control, and also increased emphasis on professional “curiosity and an investigative mind set”.

“We have restructured the command of our Criminal Investigation Department and Major Investigation Team bringing them within a single branch with a unified command of experienced senior investigating officers,” said Mr Beck.

“We have reviewed and refreshed our investigative training and death investigation instructions while enhancing supervisory standards in this regard. Safeguarding referrals in domestic abuse cases are already subject to enhanced supervisory review. Oversight structures have been reinforced to ensure clearer escalation when concerns are raised.

“We recognise that more must be done and, as part of our recovery plan, I am committed to increasing resourcing in our Publication Protection Branch.

“We are committed to rebuilding trust through action, accountability, and reform.

“I want to take this opportunity to appeal to anyone who believes they may have been a victim of Jonathan Creswell or anyone else. I would urge victims to speak to us, we are here to listen, to help and to keep you safe.”

Northern Ireland Justice Minister Naomi Long, who commissioned the review, said there was much room for improvement.

“We all know the name Katie Simpson – regrettably because of her senseless, untimely and tragic death, she said.

“We also know the name Jonathan Creswell – a convicted abuser and the man charged with Katie’s rape and murder and found dead at home on the second day of his criminal trial.

“We also know many individuals raised concerns about the circumstances surrounding Katie’s death and the investigation that followed.  May I thank all those individuals for their moral integrity, their bravery in coming forward and for their persistence. They fought to give Katie a voice; as a society, we owe them a debt of gratitude.”

In an Oral Statement to the Northern Ireland Assembly, Ms Long said: “Katie’s death was concealed and staged as suicide, and it is abundantly clear that investigative practices and mindsets must change,” she said.

“Within policing, coercive control must be recognised as a serious and potentially lethal risk factor. Patterns of behaviour, not isolated incidents, must drive assessments of risk. The Review provides a clear framework, including six new indicators of concealed homicide, which should be embedded across sudden death investigations and specialist training.

“There too, is a clear need to develop mandatory use of trauma-informed, victim centred investigative models. Information about Katie was missing from this case. Suspicious death and suicide investigations should therefore include comprehensive victim profiling.

“Relatedly, we must seek to combat cognitive bias and confirmation bias. Police officers need to be fully trained to recognise and challenge gendered stereotypes or victim blaming narratives. A lack of trust in victims and poor investigations empower perpetrators such as Jonathan Creswell.

“This also extends to forensic investigation standards in all sudden or unexplained deaths. Forensic protocols should reflect trauma-informed and gender-sensitive practices and require pathologists to consider coercive control and staged suicide as part of their analysis.”

Ms Long said the absence of specialist domestic abuse input at the earliest stages of the investigation was also “a critical failing”.

“The Review is clear: specialist Domestic Abuse Officers must be involved from day one wherever there is any history of violence within the family. We must ensure expertise is shared, not siloed,” she said.

“Police team coordination and case ownership must also improve. In Katie’s case, the investigation was passed between departments without a designated lead, causing confusion and delays. This lack of ownership contributed to missed opportunities and a failure to act on known risks.”

Responding to the review, Northern Ireland Policing Board chair Brendan Mullan said: “This comprehensive review by Dr Melia sets out in stark detail a series of missed opportunities which makes for deeply troubling reading, as is the assessment of ‘institutional misogyny’. This report also signals the urgent need for wider education on the signs of coercive control and removing the stigma of abuse in working to prevent Violence Against Women and Girls.

“The 16 recommendations from the review require both systems and attitudinal change within policing and the Criminal Justice System. “

The Board will be questioning the Chief Constable at its meeting this week (May 7) on how the listed areas for action are now fully embedded and integrated into everyday policing practice and mindset,  particularly in light of the findings from the recently published Langdale Review.

“It is welcome that the Justice Minister, in her statement to the Assembly,  acknowledged the cooperation and candour on this review.  It is only through such openness that the changes necessary can be effected so that no other victim will be failed in the way that Katie was.”