Garda Homicide Statistics: Discussion (Resumed)

The purpose of this meeting is to discuss again issues surrounding the recording and classification of Garda homicide figures including, in particular, the review being conducted by An Garda Síochána into the classification of homicides and the reasons for the delay in publishing the findings of that review and furnishing a report to the Policing Authority. I very warmly welcome here this morning Ms Lois West, deputy head of An Garda Síochána analysis service, and Ms Laura Galligan, senior crime and policing analyst with An Garda Síochána analysis service.

Before we begin, I have to indicate to members that, under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable. I draw the attention of witnesses to the situation in respect of privilege. I ask them to note that they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Without any further ado, I invite Ms West to make her opening statement. At its conclusion, we will go directly to Ms Galligan.

Ms Lois West

I thank the Chairman and the committee for the opportunity to come here today to give our evidence on the ongoing homicide review in An Garda Síochána.

I commenced my current role as deputy head of the Garda Síochána analysis service, GSAS, on 1 August 2007. As part of the GSAS management team, I have been integral to the introduction and establishment of the analysis service in An Garda Síochána. Not only has this involved recruitment, structuring, training, the development of systems and processes, progression planning and budgeting, but also gaining acceptance for the use of analysis in the wider organisation. I have responsibility for crime and policing analysts within headquarters units and special crime operations. My remit is very broad, ranging from oversight of national assessments of volume crime, such as burglary and assault, through serious and organised crime, for example, homicide, drugs and immigration, to matters concerning national security. I have insights into the organisation across the spectrum of policing functions and have experience of interacting with personnel at all grades and ranks.

Prior to August 2007, I worked as an analyst in the Police Service of Northern Ireland, PSNI, for nearly six years. During this time, I supported a multitude of investigations into serious and organised crime and delivered many reports containing operational recommendations, which were used to set organisational priorities and guide significant strategic decisions by senior officers.

In July 2016, I received a direct request for analytical assistance from the Garda national protective services bureau, GNPSB. The request was for the Garda Síochána analysis service to conduct a ten-year review of domestic homicide from 2007 to 2016. The chief superintendent who made this request did so to satisfy particular obligations the GNPSB has with respect to: the national strategy on domestic, sexual and gender-based violence from 2016 to 2021; An Garda Síochána’s domestic abuse intervention policy of 2016; the development of a risk assessment tool in An Garda Síochána; the development of divisional protective services units in An Garda Síochána to meet commitments made in the 2016 policing plan and made to the Policing Authority; the EU victims directive of 2015; the Criminal Justice (Victims of Crime) Act 2017; and the Istanbul convention, which is the Council of Europe convention on preventing and combating violence against women and domestic violence. I personally tasked senior crime and policing analyst, Ms Laura Galligan, with this review.

Ms Galligan had significant, relevant experience from her previous role as senior scientist with the Office of the State Pathologist. I believed this expertise would add great value to the review of domestic homicide.

Having been deputy head of analysis with An Garda Síochána for nearly 11 years, I have been uniquely placed to understand the organisation and identify areas of concern or weakness which require prioritisation, particularly if the transformation agenda is to succeed. Throughout my tenure with An Garda Síochána, recurrent areas of concern identified by the analysis service have been PULSE recording and data quality. Although there is no clearly defined process for GSAS to raise issues identified with regard to data quality, we have always escalated our concerns, whether to crime, policy and administration - latterly known as the policy development, implementation and monitoring unit - or the Garda information services centre in Castlebar and frequently to senior Garda management in analytical reports and at management meetings and conferences.

Data quality is of fundamental importance to analysis. A dearth of good data seriously limits the ability of an analyst to conduct complete and robust analysis in any sector. I voiced my concerns about data quality to Ms Galligan as she embarked on the ten-year review of domestic homicide. Within a short time, it became clear there was a deficit of information on the PULSE system to enable Ms Galligan to determine whether a homicide was of a domestic nature or otherwise. Ms Galligan therefore requested permission to liaise with the Office of the State Pathologist in order that she would have independent and verifiable supplementary information to ensure data quality. I take this opportunity to thank Professor Marie Cassidy and her team for engaging in this collaboration with the analysis service.

When Ms Galligan analysed and cross-checked the files held in the Office of the State Pathologist, information held on PULSE and homicide spreadsheets previously produced internally by the analysis service on a monthly basis, she identified inconsistencies which she deemed to be significant. When she brought this to my notice, I concurred with her views. I immediately recognised the gravity of the matters raised and the many possible ramifications. In my view, the issues raised went right to the heart of policing and the ability of An Garda Síochána to protect and serve the public.

While there were concerns regarding the accurate provision of crime data to the Central Statistics Office, the primary concern was with regard to the victims, their families and loved ones. I could immediately see the very serious organisational risks for An Garda Síochána in terms of reputational damage and public confidence. I asked Ms Galligan to specifically consider a sample period from 2013 to 2015 to expeditiously highlight the main concerns. I believed it was critical that we establish an evidence base to clearly illustrate the various issues arising. Ms Galligan undertook this work on the sample period as I had directed. On 24 November 2016, she emailed me a draft of her report entitled, Comparative Analysis of the Recording and Reporting of Homicide Incidents in the PULSE Database and the Office of the State Pathologist. Following a specially convened meeting on 28 November 2016, I recommended to management that the Garda executive be briefed immediately. I am aware that this briefing occurred on 29 November 2016. We understood at this time that the professional standards unit would be asked to conduct reviews of the cases highlighted. I had this impression from communications with my management. The role of the professional standards unit is to examine and review, as directed by the Garda Commissioner, the operational, administrative and management performance of An Garda Síochána at all levels; propose measures to the Commissioner to improve that performance; and promote the highest standards of practice, as measured by reference to the best standards of comparable police services, in operational, administrative and management matters relating to An Garda Síochána.

Subsequent to the briefing of the Garda executive on 29 November 2016, I asked on several occasions whether anyone had been in contact to address the matters raised. I was concerned that there did not appear to be a sense of urgency to initiate a full review on the basis of Ms Galligan's report. In mid-January 2017, officers from policy development, implementation and monitoring, or PDIM, commenced a review of 41 cases which had been referenced in Ms Galligan's draft report. The report had been escalated to management in draft format due to the urgency with which I perceived the need to raise the issues identified. It had remained in draft format as priority was given to beginning to look at other years. I did not deem it a time for worrying about perfection in report writing. For me, the emphasis was on identifying the issues and raising them as quickly as possible. Issues identified by Ms Galligan ranged from potential misclassification to data quality issues of varying degrees of severity. Ms Galligan will shortly go through the findings of her analysis.

Ms Galligan and I attended meetings with representatives from PDIM on the following dates in 2017: 17, 19 and 24 January; 7, 13, 20 and 21 February; and 2 and 30 March. We specifically requested the meeting of 30 March. After the first meeting on 17 January 2017, all relevant reports were forwarded by me to PDIM electronically with the following email:

... As a result of reviewing case files held within OSP a number of potentially serious anomalies were identified which raised the question of whether PULSE had a complete record of all homicides (not exclusively domestic). As the numbers recorded as homicide in OSP were higher, the systems had to be manually cross-referenced. This has raised the possibility that certain cases on PULSE may be incorrectly classified. In addition, a series of other data quality issues were identified.

The documents above outline the variety of issues identified. It is recommended that a review is carried out of each case noted to determine whether there is a consensus that there are matters of concern. GSAS will happily assist in any way we can. We would appreciate being kept abreast of developments as this will determine how we proceed with the review of additional years. 2012 is nearly complete and will be disseminated to you shortly. It is then intended to research 2016 as we now have a complete year of data. This will give 5 years which have been reviewed. A decision will then have to be taken as to whether we continue to work back from 2012. The original domestic homicide review was intended to cover a period of 10 years ...

During the nine aforementioned meetings, cases highlighted between the years 2013 and 2015 were discussed. These were very robust discussions, not only about each individual case but also high-level issues such as consistency in recording practice across crime types. We entered into these meetings in good faith and genuinely believed the intention was to fully and independently review each of the cases. However, as it transpired, there was an apparent reluctance to countenance many of the issues we tried to raise. We made many attempts to highlight the potential organisational risks, the inconsistencies we were identifying and the absolute need to review the approach to death classification and investigation, not only within An Garda Síochána but also in collaboration with partner agencies. We made it very clear at these review team meetings that agreement had not been reached between the parties involved on many of the key matters raised.

Although a review of 2012 had already been carried out, we were instructed not to send the related executive summary to PDIM. We were not permitted to reference cases from outside the sample review period - 2013 to 2015 - even though they were pertinent to highlighting crucial facts. Every case will have particular nuances to be referenced, some of which may ultimately impact on policy decisions.

It was my full expectation that, as Ms Galligan and I had attended all meetings of the review team, we would, in spite of the often tense and quarrelsome debates, be involved in or at least consulted on the drafting of any report concluding the findings of the meetings and putting forward any recommendations. It was our understanding that our input was necessary given our central role in raising the issue and highlighting the problems. However, instead of being consulted or involved, Ms. Galligan and I were excluded from the preparation of any report or review document. We were not consulted regarding our views on how to ensure good data quality that would enable the work of GSAS.

On Monday, 8 May 2017, I was handed a 59-page, hard-copy document entitled, Review of Specific Sudden Death/Homicide Incidents recorded during the period 2013 to 2015. This was a report produced by PDIM officers from the review team. I had inquired as to the status of such a report on 28 and 30 March and I am aware Dr. Singh, the head of GSAS, had requested on several occasions during April 2017 to be furnished with any such report. When this report was provided to me by Dr. Singh at 12.20 on the afternoon of 8 May 2017, I was informed that views on it were required by the close of business that day. This was not possible.

In this report, Ms Galligan's methodology was deemed to be "inherently weak", "confined" and "restricted" and there were repeated attempts to undermine and erode confidence in the findings of the initial sample review. This was of huge concern to me. I felt that my integrity and the integrity of my colleague, for whom I have the utmost respect, was under attack. Our concern was of a professional nature. We had been tasked with generating a report, as required by a chief superintendent.

In order to undertake the task and provide the report requested of us, we had to adhere to professional standards and norms. The fundamental and key component part of this, as any data analyst will confirm in any industry, is the underlying data quality as it underpins the analysis. Bad data will lead to bad analysis. We were concerned about the accuracy and quality of the data, and to have ignored our concerns would have been to ignore our ethics and professional standards. No engagement with the review team gave us any assurance regarding the data quality.

Over the course of 8, 9 and 10 May 2017, I believe that very significant pressures were brought to bear on Ms Galligan and me, to persuade us to sign off on the PDIM report. I felt very pressurised in heated meetings which occurred on 9 and 10 May 2017. I also received a series of telephone calls on the afternoon of 9 May during which significant pressures were brought to bear. Professionally, I could not sign off on the PDIM report and made it clear to all concerned that I would not bow to pressure. On 11 May 2017, I felt compelled personally to transmit my views about it in a five-page letter to several members of senior Garda management. Within this correspondence I noted:

My position has been very clearly stated on multiple occasions throughout this process, and remains unchanged. During the meetings between PDIM, Ms Galligan and I, no agreement was reached, either with regard to the classification of individual cases discussed, or in regard to the more strategic issues relating to homicide investigation and death classification.

To make sure there is 100% clarity, the report entitled, Review of specific Sudden Death/Homicide Incidents recorded during the period 2013 to 2015 is, in my opinion, a one sided view of what occurred within the meetings between PDIM, Ms Galligan and I. I do not agree with many aspects of the report and I therefore cannot and will not be signing off on recommendations contained therein.

At 8.50 a.m. on 12 May 2017, as a direct consequence of the letter I had sent internally the day before, I received a telephone call. In line with the requirement of the committee that persons are not named or referenced in such a way as to be identifiable, I am unable to say who made this call. During this call, I was made aware that a report, which I had submitted on 11 April 2017 for onward transmission to the Policing Authority - request 210 relating to the homicide review, had never been sent to it. I was informed that this report had been discussed among senior Garda personnel prior to a private Policing Authority meeting on 13 April 2017. If this was the case, then it was known at that time that agreement had not been reached during the meetings of the review team. This makes it difficult to understand how certain comments were made and assurances given during the public Policing Authority meeting on 27 April 2017. Several other things were said to me in this conversation, for which I have contemporaneous notes and which I can make available if the committee requires.

On the afternoon of 12 May 2017, Ms Galligan and I met with members of senior Garda management. We were very honest about our views during this meeting. It was made clear that there had been difficulties during the review team meetings and that we felt we had not been listened to or well treated. Following this discussion, it was agreed that there still needed to be a firm decision taken on the classification of a number of cases highlighted in Ms Galligan’s original report. During this meeting, and in a subsequent email I sent on 13 May 2017, there was agreement that Ms Galligan and I would be given sufficient time to go through the PDIM report, review the conclusions of this report vis-à-vis our own conclusions relating to the 41 referenced cases and provide a response to the report. There was also to be a meeting convened immediately to address the difficulties which had arisen at the review team meetings. This meeting eventually took place on 26 June 2017 but unfortunately resolved nothing.

On 26 May 2017, a draft response was provided to senior Garda management, which included the agreed review of the 41 cases. A 123-page final report was submitted to senior Garda management on 7 June 2017. This final version of the report included 20 pages of recommendations, made on the basis of the findings of the 2013 to 2015 review. On 30 June 2017, another member of senior Garda management was also briefed by Ms Galligan and me, as the member was to set up a multi-agency working group to deal with policy and governance issues arising. This group was to include representatives from the Central Statistics Office, the Policing Authority and the Department of Justice and Equality, among others.

In the weeks that followed, Ms Galligan continued to produce reports identifying cases of concern for 2017. These reports were escalated to senior Garda management. Again, these concerns related to potential misclassification of incidents and broader data quality issues. Ms Galligan also continued to provide assistance with rectifying issues uncovered with regard to fatal collisions and incidents of dangerous driving causing death. Ms Galligan also continued to refer cases to the protective services bureau, where we had very genuine concerns that a person may be living in a vulnerable situation. For example, we made the decision to escalate cases where we felt that a new partner may be at risk. These were identified as Ms Galligan did her utmost to piece together histories where escalation in the number and severity of incidents pointed to significant risk indicators. At times this was like stitching together a patchwork quilt, as there were incidents that were correctly classified and then there were those found languishing in inappropriate categories, such as attention and complaints. I strongly believed that we would never regret referring such instances to the protective services bureau, but we might regret not doing so.

I continued to pursue senior Garda management for responses and guidance as to how we should proceed with the review of other years. I was concerned that GSAS had been tasked with reviewing a ten-year period and only four years had been initially reviewed, with much more work required. Between May and mid-September 2017, we continued to come under pressure to come to agreement regarding the 41 cases. However, even following adjudication by a member of senior Garda management, agreement could not be reached because the stance was still to insist there was nothing wrong. In mid-September 2017, Ms Galligan and I were informed that we had indeed been correct all along and that there were cases which had been misclassified. This gave us an immense sense of relief and confirmed that we had been correct in standing our ground. However, we have yet to receive any formal guidance as to what is required of us.

In particular, the stress and pressure we had been subjected to on a continual basis from our first raising these issues have not been satisfactorily acknowledged or adequately addressed. It is my view that we were subjected to severe pressure to withdraw our concerns, to ignore our professional standards and to agree with the views of the sworn members of the review team. Our integrity, both personal and professional, was undermined and attacked. We do not know what the motivation of the review team was in disregarding our views, seeking to minimise the importance of the issues and then seeking to force its report on us and have us sign off on same, inclusive of the scant and inadequate recommendations contained therein.

On 11 December 2017, Ms Galligan and I requested, by email, a private meeting with senior Garda management due to our ongoing concerns about the lack of progress. This email seemed to set in motion the appointment of another member of senior Garda management to lead on the homicide review. Our private meeting with senior Garda management occurred on 10 January 2018. Ms Galligan and I also wrote to senior Garda management again on 12 January 2018. While this seemed to promote some further activity, it would seem that recent media coverage of the homicide review and the intervention of the justice committee have led to the most significant progress to date.

Such was our level of concern at certain points of the process that we made attempts to engage with the Policing Authority by telephone or in writing on the following dates in 2017: 3 April; 16 May; 30 June; and 19 July. As outlined earlier, a report was also prepared on 11 April 2017 for onward transmission to the Policing Authority, but I subsequently discovered on 12 May 2017 that this report had never been sent to the authority. I do not understand the rationale for this, as there was no sensitive, case-specific information included. On 1 August 2017, I was told by a member of management that the member had been informed by a member of the Policing Authority, over the telephone, about the approaches I had made to the authority. This was raised with me in the context of management trying to ascertain what my thinking was when I did this. To date, we have met no one from the Policing Authority regarding the homicide review.

Ms Galligan and I are fully committed to doing everything possible to brief and support the newly established working group, which met properly for the first time on 19 February 2018. We may be about to achieve the full and independent review of death classification and investigation that we have been consistently seeking since November 2016. However, we still have no formal written direction as to what is required of us into the future or clarity as to how this will be balanced with existing demands. Most notably, Ms Galligan’s original methodology, which was the subject of particular attack, will form the cornerstone of the new working group.

We hope that a multi-agency group will soon be established to address the policy, governance and education aspects of the review as raised in our report of 7 June 2017. We continue to have serious concerns about what will be done to address misclassification and data quality into 2018. We are unaware of any current monitoring of the issue and, to our knowledge, no process has yet been agreed in that regard.

I thank Ms West for a very comprehensive presentation. I welcome her colleague, Ms Galligan, whom I call on to make her opening statement.

Ms Laura Galligan

I thank the Chairman and members for the opportunity to address the committee and discuss current issues relating to the recording and classification of Garda homicide figures. I am a senior crime and policing analyst in An Garda Síochána. I work within the Garda Síochána analysis service, GSAS, and have been attached to special crime operations since June 2016. From 2012 to 2016, I worked in the position of the senior scientist in the Office of the State Pathologist and had sole responsibility for the management and running of the laboratory, where I performed all histopathological tests on samples from State post mortems performed by the State pathologists. I also accompanied the forensic pathologists to crime scenes and assisted them in post mortem examinations. My educational background includes a five-year honours degree in biomedical science and a postgraduate qualification in forensic medicine. I am currently undertaking a professional certificate in governance.

In July 2016, my line manager, Ms West, assigned me responsibility for a ten-year domestic homicide review from 2007 to 2016 as requested by the Garda national protective services bureau. Ms West had from the outset expressed general concerns about the data quality on the PULSE system. To prepare for the assessment of how the ten-year review could be undertaken, I carried out an initial overview analysis of information contained on PULSE in regard to the homicide categories. This involved assessing how easy it would be to recognise a homicide with a domestic element.

In September 2016, a meeting was held with the chief superintendent of the Garda national protective services bureau to discuss the action plan of the task. With prior permission from Ms West, I suggested working in collaboration with the Office of the State Pathologist as, from my previous experience, I was aware the records of that office may contain more information on whether there was a domestic element to the death, which would greatly assist me in undertaking the ten-year review. The suggestion was very much welcomed by the chief superintendent and other members of the Garda national protective services bureau.

I had met the State pathologist, Professor Marie Cassidy, to ascertain her interest in the work and wrote to her on 8 September 2016 requesting an agreement to collaborate data and information to carry out the review between the Office of the State Pathologist and the Garda Síochána analysis service. On 14 September 2016, Professor Cassidy wrote to me to confirm her agreement to the collaboration. I would like to take this opportunity to thank Professor Marie Cassidy, Dr. Linda Mulligan, Dr. Michael Curtis, Dr. Margot Bolster and all staff in the Office of the State Pathologist for accommodating the review as well as the professional support and advice they have continually offered me.

I compiled a domestic homicide review proposal which was sent to Ms West and the chief superintendent in the Garda national protective services bureau. I set out the methodology I would utilise to conduct as comprehensive an analysis as possible and designed a template qualitative data sheet.

GSAS produces an internal homicide spreadsheet every month. I was the analyst responsible for the spreadsheet in September to December, inclusive, in 2016. In the four months I produced the spreadsheet, I noted the absence of a number of homicides from 2016 which were recorded as non-crime incidents of sudden death.

I commenced my analysis at the beginning of October 2016, utilising records from the Office of the State Pathologist, information on PULSE and the homicide spreadsheets produced monthly by GSAS for internal use. When I reviewed the post mortem report and the circumstances surrounding the death, with consultation with the relevant forensic pathologist if required, I scrutinised PULSE for the recording of the death and other data quality parameters. For no particular reason, I began with the year 2014 but quickly realised that there were inconsistencies evident with homicide and death classification as well as many data quality issues. I immediately raised my concerns with my line manager, Ms West.

Following a period of three weeks in October 2016 when I was abroad on training for An Garda Síochána, I resumed the homicide review in November 2016. Ms West asked me specifically to consider a period of three years to ascertain any inconsistencies and the varying issues I had identified. We decided to conclude with a sample of three years as it was pertinent that the issue be raised with Garda management as soon as possible. On 24 November 2016, I emailed to GSAS management an 87-page report entitled Comparative Analysis of the Recording and Reporting of Homicide Incidents in the PULSE Database and the Office of the State Pathologist. It regarded 43 cases I identified within the time period of 2013 to 2015, not all of which were potential homicides. There were many areas of concern in regard to misclassification, under-reporting, over-reporting, delay in recording, and data quality issues. I reviewed 524 deaths in total for that period.

There were four main areas of concern: deaths that were pathologically considered to be a homicide but recorded in the incorrect crime category and-or a non-crime category; deaths that were recorded at a later date as a homicide and-or recorded as occurring in the incorrect year; deaths deemed suspicious by virtue of cause of death and in which criminal involvement would be determined by Garda investigation but which were recorded in a non-crime category or no category; and deaths that had varying data quality issues such as the deceased not being marked as such on PULSE, an incorrect "weapon used" or date of birth being recorded for the deceased, or the incorrect Garda district or division being recorded for the death.

In mid-January 2017, a review group comprising myself, Ms West and officers from policy development, implementation and monitoring, PDIM, was created. PDIM stated that two of the 43 deaths with which I had raised issue in the report from 2013 to 2015 would not be considered in the review for reasons that cannot be publicly disclosed due to legislative frameworks, and 41 cases were, therefore, the subject of review between PDIM and GSAS. As mentioned by Ms West, nine meetings were held between January and March 2017 attended by individuals from PDIM, Ms West and me. Robust discussions were had at the meetings and Ms West and I voiced our concerns at what we deemed a very serious issue of the recording and classification of deaths within An Garda Síochána. However, we were not given the professional respect we deserved and, at times, I felt we were belittled and treated very poorly. At no stage during the nine meetings was the methodology I utilised questioned by members of PDIM or referred to as weak.

During those months, I began interrogating the PULSE database to try to determine a little more background on how deaths can be and are recorded in An Garda Síochána. I identified that there are 16 incident categories on PULSE under which a death could potentially be recorded. I considered this a significant number of ways to record a death and the categories were extremely varied in their descriptions according to the PULSE creation manual. I continued to analyse the PULSE database and discovered that there are no identifiable parameters on PULSE for fatal or non-fatal hit-and-run incidents. On inspection of some fatal hit-and-run incidents, I discovered they were all recorded as traffic collision fatal incidents, which is a non-crime category, but a criminal investigation is initiated from the time of such incident occurring. I raised these issues among many others during the nine meetings with PDIM but we were quickly told they were not up for discussion and only the 41 cases were to be reviewed. We felt that the various issues I was identifying were critical to highlighting the facts of misclassification in the recording of all types of deaths.

In January 2017, having continued the analysis of deaths in 2012, I wrote an 81-page report on various cases with serious anomalies and sent it to Ms West. Areas of concern were consistent with the previous report and others identified were: deaths recorded in non-death categories such as missing persons, public order offences and attention and complaints; deaths being counted twice; and deaths not recorded for significant periods of time after they had occurred. Although this report was completed, PDIM gave strict instructions not to be sent the report as it was not reviewing any more than the 41 cases from the three-year period.

Within this timeframe, I identified other issues that I immediately raised to various individuals in management. I raised an incident of serious concern to the Garda national protective services bureau upon discovering that the partner of a deceased person was in a new domestic violent relationship. I have since highlighted several such cases to the Garda national protective services bureau and that led to the establishment of Operation Devise, in which I have been involved. I highlighted an incident that I had discussed with the chief superintendent in the Garda national protective services bureau which was recorded as a non-crime incident but was a domestic murder-suicide incident. Following inquiries with the relevant division by the chief superintendent, the incident was appropriately reclassified that evening.

In February, I had a routine meeting with my manager, Ms West, during which I expressed my concerns at GSAS continuing to produce the monthly homicide spreadsheet in view of our being unable to guarantee the accuracy of PULSE. It was agreed with Ms West that I would review January 2017, in collaboration with Professor Marie Cassidy and the Office of the State Pathologist, to compare the cases carried out and the corresponding PULSE incident recorded. In March 2017, I wrote a report entitled Data Quality Issues with Death Classification 2017 which was sent to management. There were many areas of concern in terms of misclassification, under-reporting, over-reporting, delay in recording, and data quality issues.

There were three unrecorded homicides as of the end of February 2017. One of the unrecorded homicides was raised at a senior leadership meeting the next day. It still remained recorded incorrectly for a further six months, despite being highlighted numerous times. There were cases with the following concerns: homicides misclassified; suicides misclassified; hit-and-run incidents recorded as non-crime traffic fatal incidents; suspicious deaths under sudden death classification; and natural deaths containing PULSE data quality issue.

At the end of April 2017, I was extremely surprised when it was announced in the media that the review into homicides was complete, and the conclusion was that there were only "minor misclassifications". It was at the public Policing Authority meeting on 27 April that we became aware that the review team had written a report. Neither Ms West nor I, as part of the review team, had any input nor were our views taken into consideration in the drafting of the report. On receipt of the report on 8 May, it became immediately clear why the report was not shared with us. On reading of the report, I felt very personally insulted by the commentary regarding my work and my methodology. As previously mentioned, at no stage during the nine meetings was any criticism voiced regarding the inappropriateness of my methodology. It had now been concluded that the methodology I had utilised in comparing the records of the OSP and the PULSE system was "inherently weak", "inappropriate", "confined" and "restricted". The days between 8 and 10 May were troublesome, in that PDIM brought significant pressures to sign off on the report that we had only just received. Like Ms West, I professionally and ethically could not agree to a report I knew was completely inaccurate and misleading. I remained assured that there were homicides misclassified and incorrectly recorded.

In May 2017, I wrote a report entitled Homicide and Suspicious Death Incidents 2017: PULSE Categorisation & Office of the State Pathologist Categorisation, which was sent to management. There were many areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, such as 33 homicides recorded as of May 2017, three of which did not occur in 2017 but would be counted by the CSO; six unrecorded homicides recorded as follows: non-crime incidents of person misadventure - sudden death; non-fatal incidents of assault causing harm; and non-fatal incidents of discharging a firearm. There were a number of fatal hit-and-run traffic incidents in 2017, all of which are unidentifiable in the recording on PULSE. These incidents are routinely recorded as a non-crime incident of traffic - traffic collision fatal when a criminal investigation is ongoing. In the email sending this report, I stated:

There are many victims going unnoticed by this organisation the longer this goes on. When these cases are being recorded as a non-crime category of Sudden Death or even Discharging a Firearm, is there any follow up with the victim’s family or liaison with a FLO. Is there even a FLO being assigned? The deceased victims have not been given the respect and duty of investigation into their deaths that they deserve. Sadly, the majority of 2017 homicides are of a domestic nature, again going unreported.

This is 2017 in four months 2013 to 2015 we are now satisfied that PDIM have reviewed, but see nothing but ‘minor inaccuracies’, which is completely incorrect. I am not going to lose my work ethic or determination over this, and one didn’t build Rome in a day. However, I cannot continue to identify incidents of homicide as we continue in 2017 that are not recorded correctly or not knowing whether there is an adequate investigation being carried out into that person’s death.

In June 2017, I wrote a report entitled Homicide and Suspicious Death Incidents 2017 – Month Ending May 2017, which was sent directly to senior Garda management. There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as 18 homicides recorded as of May 2017, three of which did not occur in 2017 but would be counted by the CSO; six unrecorded homicides, still unchanged from previous report; ten suspicious deaths being recorded under a non-crime classification, although a criminal investigation was initiated; and a number of fatal hit-and-run traffic incidents in 2017, all of which were recorded as a non-crime incident of traffic - traffic collision fatal.

In July 2017, I wrote a report entitled Homicide and Suspicious Death Incidents 2017 – Month Ending June 2017, which was sent directly to senior Garda management again. There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as 20 homicides recorded as of May 2017, three of which did not occur in 2017 but would be counted by the CSO; nine unrecorded homicides recorded in non-crime or a non-fatal crime incident type; ten suspicious deaths being recorded under a non-crime classification, although a criminal investigation was initiated; and a number of fatal hit-and-run traffic incidents in 2017 recorded as a non-crime incident of traffic collision fatal, when a criminal investigation was ongoing.

In August 2017, I wrote a report entitled Traffic: Dangerous Driving Causing Death Incidents: PULSE Categorisation analysis 2003-2017, which was sent to management. There were many areas of concern in the recording of the dangerous driving death incident type over the years 2003 to 2017.

I also wrote a report in August 2017 entitled Review of 2006 Homicides – Murder and Manslaughter: PULSE Categorisation Analysis, and sent this to GSAS management for onward transmission. This was an overview document regarding the adherence to crime counting rule 3.1 in 2006. As per headquarters directive 139/03, section 3.1 states, "A reclassification within homicide occurs where a murder is reclassified to manslaughter when a charge of manslaughter commences or when a murder charge results in a conviction for manslaughter". This review analysed conviction records and detection status for all homicide incidents as well.

In October 2017, I wrote two reports entitled Homicide and Suspicious Death Incidents 2017 – Month Ending September 2017, and An Analysis of Death Incidents – September 2017, which were sent directly to senior management. There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues such as 37 homicides recorded as of May 2017, seven of which did not occur in 2017 but would be counted by the CSO; six unrecorded homicides recorded in non-crime or a non-fatal crime incident type - a number of the previous highlighted misclassified homicides had been reclassified to a homicide so there were new homicides; 11 suspicious deaths being recorded under a non-crime classification although a criminal investigation was initiated; and six fatal hit-and-run traffic incidents recorded in 2017 as a non-crime incident of traffic collision fatal. I also had queries as to why in some deaths with concerning details the State Pathologist was not requested when a crime scene was held at the death. There were deaths that should be classified as suicide or that had a suicide incident recorded which resulted in double counting of the death, according to the detail in the narrative. There were varying data quality issues.

In November 2017, I wrote a report entitled Homicide and Suspicious Death Incidents 2017 – Month Ending October 2017, which was sent to management. There were the same areas of concern continuing in misclassification, under-reporting, over-reporting, delay in recording, and data quality issues, as well as new cases emerging that had issues, such as 40 homicides recorded as of October 2017, seven of which did not occur in 2017 but would be counted by the CSO; five unrecorded homicides, recorded in non-crime or a non-fatal crime incident type; 13 suspicious deaths being recorded under a non-crime incident, although a criminal investigation was initiated; a number of fatal hit-and-run traffic incidents in 2017 recorded as the non-crime incident of traffic collision fatal; 18 dangerous driving causing death incidents recorded for 2017, four of which did not occur in 2017, one had been invalidated, and one had three fatalities but only one crime incident when there should have been one for each victim; and 95 deaths in October with varying types of data quality issues.

I have continued to highlight to the current day cases that I believe are of concern in areas of homicide, traffic fatal incidents, suicide, sudden death and, indeed, homicide attempts. The classification of death incidents on PULSE requires an urgent review and needs to be simplified. The review of the classification comparing PULSE and the OSP is based on the pathological classification, but the ultimate arbitrator of the classification of death is the coroner. Unfortunately, coroners do not publish statistics. I have been directed to complete a review of all files in the OSP between 2003 and 2017, totalling more than 3,000 deaths, for classification purposes and investigation review using the methodology from the initial review. I will endeavour to complete this as quickly as is possible and also to complete the requested domestic homicide review that was initially requested by the Garda national protective services bureau. I will continually strive as an analyst in An Garda Síochána to ensure every death is recorded correctly, not just for statistical purposes but mainly for the victims and their families.

I thank the Chairman for the invitation to appear before the committee to provide clarity and context to the work that we do.

I thank Ms Galligan. As I indicated to Ms West, I offer a special thanks to her for a comprehensive statement. I will open the floor to members who have specific questions. Deputy Jack Chambers got in first.

However, he will have to leave shortly for personal reasons.

I thank the two delegates for appearing before us and giving a very courageous account of what they have experienced as civilians working in An Garda Síochána. Their presentations illustrate very concerning levels of dysfunction at an organisational level where there is a clear mismatch between what is being pronounced publicly or to us as committee members and what is happening behind closed doors. It is a case of déjà vu with respect to data and the PULSE system. Clearly, there are systemic problems. Ms West and Ms Galligan commenced a review and were part of the group which held nine meetings. Ms West has mentioned that she was instructed not to send the summary to the policy development, implementation and monitoring, PDIM, group. What does she believe was the motivation behind stopping the summary being sent to that group?

Ms Lois West

There might have been a number of reasons. When we inquired, the rationale we were given was the particular group had been given a very narrow brief, that it had only been asked to look at the particular sample period between 2013 and 2015, whereas Ms Galligan and I had entered into the project on the understanding it was a much bigger, broader piece of work.

On the report presented to the Policing Authority, private correspondence was sent to the group stating some of the recommendations which had been made or the data quality were or was inherently weak, confined or restricted. Who authored that criticism?

Ms Laura Galligan

It was authored by members of the PDIM group.

Who led the PDIM group at the time?

Ms Lois West

At the time it would have been under an assistant commissioner who has since retired.

At that stage Ms West felt her integrity was under attack.

Ms Lois West

Yes; I was not happy at all. As Ms Galligan said in her presentation, it was during the course of the public meeting of the Policing Authority on 27 April 2017 that we learned of the existence of such a report. To this day, I am not clear if that report or a very refined version of it was sent to the Policing Authority. Ms Galligan's expertise and background are clear from her presentation and I felt it was an insult to the work she had done. Also, as her line manager, I have a duty of care towards her and felt that it was incumbent on me to give a full and robust response to the report. As I said, we only came into possession of it on 8 May 2017 and at the time we asked that we be given additional time to go through it in detail. We also needed to revisit the original 87-page report Ms Galligan had submitted in November 2016 and compare and contrast the findings on the 41 cases.

There was pressure to sign off on the report. Who applied that pressure?

Ms Lois West

The pressure to do so came on at a couple of meetings that occurred at the time. We understood there was to be a meeting on 10 May. Our management was to be present, plus members of the PDIM group who had been part of the review team with us. They were very tense meetings at which there were raised voices and it got was very heated. We are not sure from where the ultimate pressure was coming to sign off on the 41 cases. In particular, within the PDIM group's report there were four or five very basic recommendations which we did not believe went any of the way towards addressing the issues that had been raised, but there certainly seemed to be pressure coming from somewhere to sign off on the recommendations. I am not sure if it was to satisfy a requirement for the Policing Authority or something else, but we certainly felt significant pressure was being brought to bear at those meetings. As I said in my statement, I also received telephone calls.

Was it pressure to sign off on the report or to change the approach to the way the group had analysed the data? Both delegates have mentioned in their evidence that there had been no disagreement at the nine previous meetings and that there had been a collaborative approach to trying to address the issues involved. Was it purely pressure to sign off on the report or was there the crux of a disagreement on the backdrop to the data analysis?

Ms Lois West

No; I do not believe there was any disagreement at the time on the methodology used. It only became clear when we saw the report coming through. It had not really been discussed at the meetings. To us, it felt more as if there was pressure from somewhere to get the report across the line and to have something delivered, but, as we said, we could not agree with it. We stood firm and did not agree to sign off on it.

Ms West has also mentioned that there was a conversation in August between the Policing Authority and An Garda Síochána and that contact was made about the information that had been withheld but not by the Policing Authority. Contact was made by someone within An Garda Síochána. Was she concerned that the Policing Authority had made no contact with her or Ms Galligan?

Ms Lois West

I have to be honest and say yes, I was very concerned. Earlier I noted the dates on which we had tried to make contact. On the first two occasions it was an attempt to make contact by telephone. On the third occasion, on 30 June 2017, we wrote in quite some detail because we were very concerned about statements that had been made during the public meeting of the Policing Authority on 29 June 2017. When we wrote again on 19 July, it was in response to a letter we had received from the Policing Authority asking if it would be possible to share the letter with Garda colleagues to obtain their responses. Unfortunately, at the time we felt it would not be pertinent to do so as we were already facing certain adversity. The workplace has not been particularly pleasant for either of us for the past 15 months and at the time we felt it would be too inflammatory.

Ms West was concerned that the Policing Authority had made no attempt to engage with her on the issues she had brought to bear.

Ms Lois West

Yes; I am sure it must have had a rationale. I know that there are governance structures in place and chains of command, but I felt that if I was in that position and had people who clearly wanted to tell me something or be sure I was in possession of all the facts, I would have wanted to sit down and listen to what they had to say.

Ms Galligan has given a comprehensive breakdown of the data from June, July, September and October. There are four sets of data - four reports - for the homicide and suspicious death incidents. There appears to be a growing number in each of the metrics used for homicides, the unrecorded numbers, deaths where there was no crime, where there was suspicion regarding a death and fatal hit and runs. It is clear that there is a rolling discovery that occurred last year. Has the matter been rectified or does Ms Galligan believe there are still problems with the core pillars she has outlined in the submission?

Ms Laura Galligan

As I did not review the last two months of 2017, I have to review the months of November and December, but in writing all of these reports which were being sent to management, nothing was changing. They were falling on deaf ears. I have not yet been tasked to look at 2018 to see if the problem is recurring.

Would it be fair to say that for every month Ms Galligan checked in 2017, there was a growing number of issues in the live recording of data in the data sets she examined?

Ms Laura Galligan


There were no subsequent changes to the data fields or data recorded made when Ms Galligan submitted them to-----

Ms Laura Galligan

There were some. As I said, there was a change which I believe was made between the May and June reports.

There were still six but it was six different homicides. Some of them had been changed but also there were some new ones that were misrecorded.

New ones were discovered. Did Ms Galligan say there were 95 data quality-related deaths?

Ms Laura Galligan

For the months of October and September, I decided to look at every death and not just homicides. I looked at every single death recorded on the PULSE system by An Garda Síochána within the 16 categories of death. I did a more in-depth analysis to pick up on more issues in respect of data quality and to see if there were more issues, as I mentioned in my statement. Within that month, yes there were 95 deaths with data quality issues.

Is Ms Galligan confident that in the months from then to now, there has been an improvement in the data recording of deaths?

Ms Laura Galligan

I am not confident, on looking at some particular cases on an ongoing basis for 2018. I refer not just to homicides but to other incident types.

Has the witness looked at the cases this year?

Ms Laura Galligan

No, I have not.

To go back, Dr. Singh told us some weeks ago that the September report was approved by him and he was happy to stand over it. Is Ms Galligan happy to stand over the September report?

Ms Lois West

It was in mid-September we felt there was a dramatic U-turn. Until that point, there was pressure on us to agree on the 41, but on the basis there was little wrong with them. We are not quite sure ourselves what happened between 13 and 14 September 2017. However, on the morning of 14 September 2017, I became aware that 41 Excel spreadsheets had been disseminated down, albeit not to us. When the person who brought these to my attention opened the first one, I was shocked to discover that it was actually now noted as one that needed to be reclassified and that continued. As each one was opened, we were surprised because up to that point there had been no agreement that there was anything wrong.

The report in September was very different to the one the witnesses read in May.

Ms Laura Galligan

Yes. There were 12 new homicides.

Yes. An Garda Síochána informed this committee there was an error and that it related to a slight interpretation difference. Do the witnesses want to comment on that?

Ms Lois West

I think this probably relates to the crime counting rules. That would be one of the issues we identified in the course of this work. It definitely appears as though there have been slightly different interpretations of the crime counting rules. To us it was very clear that if, for example, a person was the victim of an assault and some time subsequent to that assault he or she passed away as a result, that would immediately warrant that incident being upgraded to a homicide.

In reality, what was happening in a lot of cases was that a sudden death incident was being created to reflect the fact that the person had died. That may have happened because he or she had passed away in a hospital in another district. However, there did not seem to be this correct interpretation of the crime counting rules that when a person passed away as the result of an assault, it was immediately to be upgraded to a homicide on the PULSE system.

We were told six months would be the timeline for completion of the overall broadened review of this. Does Ms Galligan think that is achievable or will happen within the timeframe in light of the other delays we have seen?

Ms Laura Galligan

When I begin going back through the years in the Office of the State Pathologist, I do not know how many cases there are. It was 43 within three years. I do not know what it is going to be for every year. It is difficult to set a timeline on it.

This is my final question because I must leave. We are looking at a specific data set. This concerns the CSO and others, and we have concerns. We have had the breath test issue as well. Are the witnesses aware of any other areas of concern around data and data recording that should be explored further?

Ms Lois West

In the entire time that the Garda Síochána analysis service, GSAS, has been in existence, we have always brought matters of data quality concern to senior Garda management or to our recording centre in Castlebar. A small data quality unit has been established within the information services centre in Castlebar. I am sure that is making a difference in respect of data quality. However, we have also raised concerns about the limitations of that. A data quality group can only make an assessment on the basis of the information that is on PULSE.

As an example, if an incident is created as an assault but there was actually a fatality, that would not be apparent to the information services centre. It would make the presumption that the incident was classified correctly when indeed it is not. It should be a homicide. Yes, I have ongoing data quality concerns. I do not necessarily feel it would be pertinent to get into the specifics of other issues today but it is an ongoing problem and something with which An Garda Síochána does struggle.

Do the witnesses have any examples of other data fields they feel should be further explored?

Ms Lois West

One of the biggest issues has been borne out in the work done in the course of this particular task. There are a number of discriminatory or motivating factors for an incident. Domestic abuse is one, there also is one for hate crime and there are a number of others. There is a lack of consistency in completing those fields. In a majority of cases they are just not filled out at all. As analysts, we are scientists who use data and these are the fields we would use to try to aggregate data to be able to look at particular trends.

It has always been difficult for us to do any kind of quality reporting in respect of hate crime and domestic incidents for that reason. It becomes a very manual process where an analyst actually has to go in and trawl through what is called the PULSE narrative. A small amount of information is entered into the PULSE narrative about the incident. Sometimes it might say in there that it is a domestic incident, for example, a husband and a wife. However, that does not translate into the motivating factor being ticked for domestic and that is really the way the figures are compiled. That is a big problem.

I thank the witnesses.

I thank Deputy Chambers. Before I ask Deputy O'Callaghan to come in, in deference to our visitors and members, at the end of Deputy O'Callaghan's engagement with the witnesses, we are going to take a five minute sos, for toilet purposes or whatever in order that everybody is comfortable throughout the session. I call on Deputy O'Callaghan.

I thank both witnesses for accepting the invitation of this committee. It is an area on which the committee is working and members had other witnesses before them a number of weeks ago. Hearing the witnesses' evidence is very helpful to the committee. I will ask Ms West a number of questions to get a broad summary of what I think are some of the crucial aspects that have been identified. In July 2016, her bureau was requested to conduct a review of domestic homicides for ten years, that is, from 2007 to 2016. Is that correct?

Ms Lois West

Yes, it is.

Ms West then asked Ms Galligan to engage in that work and conduct the research.

Ms Lois West

That is correct.

There is nothing really unusual about that. It is part of the analysis service's function to look at data and to conduct reviews. Is it the case that there was nothing unusual up to then?

Ms Lois West

Absolutely not. It also is part of my role to look at the skill set across the service, see what analysts have which particular skills and then to try to match the task at hand to the person with the requisite skill and capacity to take on the task. Although Ms Galligan had only been in the organisation for a short time, I felt her background gave the requisite skill to bring added value to this particular piece of work.

When Ms West refers to Ms Galligan's background, she is probably talking about the fact that she had knowledge and experience in the Office of the State Pathologist and that was a requirement.

Ms Lois West

Yes, that and an extensive educational background in medical science.

Ms Galligan's work commenced when she went off and conducted research looking at PULSE, reports in the Office of the State Pathologist and other documentation. She then came back to Ms West in November with her analysis and initial review. Is that correct?

Ms Lois West

That is correct. We had a lot of conversations back and forth at the time. It was several times a day. I remember a particular email to Ms Galligan on 22 November 2016 where I said we really need to be very explicit about what the issues are here.

I believe my words in the email were: "We need to smack the organisation around the face with this. This is potentially very explosive if we are correct."

She identified inconsistencies that she deemed very significant. Is that not correct? She brought them to Ms West's attention and she agreed with this.

Ms Lois West


Ms West says in her statement that, in her view, the issues raised went right to the heart of policing and the ability of An Garda Síochána to protect and serve the public. Could she elaborate on that for the committee? Why did she believe these issues went to the heart of the ability of An Garda Síochána to protect and serve the public?

Ms Lois West

As was noted during the justice committee meeting a couple of weeks ago, if there is a cavalier attitude to data and data quality, it perhaps has a much more significant impact on the ability to police than the ordinary Garda member on the street might realise. It spans very many different areas, from being able to ascertain our crime levels to the deployment of resources, for example. In this particular work, we were concerned whether, if the incidents were not being captured correctly on the PULSE system as homicide, there were other issues. Certainly with regard to some incidents, we did begin to raise some concerns that the investigations perhaps needed to be reviewed, just to be on the safe side.

As I said to Deputy Chambers, there is a very significant issue when complete and accurate data are not entered on the PULSE system. We, as analysts trying to use the data at the other end, cannot give a robust and complete analysis if we do not have accurate and complete data. It becomes very concerning for me in regard to areas such as domestic abuse. Deputy Clare Daly raised this a couple of weeks ago. Any research done on domestic abuse points to there being an escalation in incidents in the types of scenarios in question. Therefore, it is essential to capture even the smallest of incidents where gardaí are called out to a property and where there may be nothing to see there at the time. It may, however, be the beginning of a pattern or escalation. In order to be able to protect vulnerable citizens in their own homes across this country, we need to be able to identify where there is an escalation with regard to this type of incident.

When the data are not accurate, it deprives members of An Garda Síochána of access to the relevant history pertaining to a potential suspect.

Ms Lois West

Yes, it does. There is also an element in regard to vetting if incidents are not recorded on the PULSE system correctly and if suspected offenders are not correctly linked to incidents, for example. I am concerned that when we are vetting people for positions in which they might be interacting with vulnerable people, we could be missing things.

On 24 November, Ms Galligan sent Ms West a draft of her 87-page report. Ms West recognised that this was extremely serious. She wanted it brought to the attention of the Garda executive. Is that not correct?

Ms Lois West

That is correct.

Could Ms Lois West remind the committee who is on the Garda executive?

Ms Lois West

There are a number of members on the executive. They include the Commissioner, the deputy commissioner, if there is one or two at any given time, and the chief administrative officer. As I understand it, when the briefing of the senior executive occurred on 29 November, two members of the executive were briefed.

Therefore, Ms West is aware that the Garda executive was informed of this on 29 November. Up to that stage, everything seemed to be working according to plan and Ms West had no complaint about any issue. Is that not so?

Ms Lois West


Let me outline what appears to me to be the problem period. Between 1 December and the time of the Policing Authority meeting on 27 April 2017, Ms West's work seems to have been ignored and she seems to have been excluded from deliberations. Would that be a fair assessment of what occurred?

Ms Lois West

I believe a fair assessment would probably be that from 1 December right through until mid-September, we felt that way. Certainly, the Policing Authority meeting of 27 April 2017 was a particular landmark but, as I stated, we still had concerns that, up as far as the meeting of the Policing Authority on 29 June and beyond that, nothing was changing and we were not getting the traction we believed we should get.

On one level, there are the issues about the work of Ms West's service not being taken seriously. On the other hand, in terms of the major public issue, why were the issues Ms West raised and highlighted not countenanced in the report? Why was there an attempt not to give credence to them?

Ms Lois West

It may be one of two things. There may be more, depending on one's viewpoint. It was either the case that there was a failure to grasp the gravity of the situation and the potential ramifications of it or it was the opposite, which meant it was grasped and that there was fear about how expensive and comprehensive an issue it was.

Let us put ourselves back into the early part of last year in An Garda Síochána. There were major issues developing in respect of Garda breath-testing, as referred to by Deputy Chambers. Might it have been a factor that the Garda did not want to put into the public domain further negative information in respect of Garda data?

Ms Lois West

Any answer we would give to that would be purely speculative.

I refer Ms West to the Policing Authority meeting of 27 April 2017. Does she believe the authority was given an accurate account of the state of the homicide review in An Garda Síochána at that time?

Ms Lois West

No, I do not.

I asked Dr. Singh about this three weeks ago. The impression appears to have been communicated clearly to the Policing Authority that the analysis and investigative sides of the house were satisfied. Was that correct at the time?

Ms Lois West

Absolutely not.

Did Ms West see the Policing Authority meeting as it was taking place? Did she see it subsequently?

Ms Lois West

I believe Ms Galligan and I have probably watched all the meetings as they happened, with great interest.

What was Ms West's reaction to it?

Ms Lois West

I believe I sent some messages during the meeting to express that we were not happy. I believe it was alluded to during the meeting that it had been a full and independent review, which we simply did not agree with. We were also deeply concerned that we were being bound to the idea of a joint enterprise. There were indeed joint meetings involving the review team. We dutifully attended all nine with the members of the policy development, implementation and monitoring section but, as I noted in my statement, we were not involved in or consulted on the drafting of the subsequent report.

The report that was referred to the Policing Authority meeting was not really the product of work conducted by the analysis service and the investigative service; it was purely work produced by the latter.

Ms Lois West

I feel it was certainly the conclusions drawn by the policy development, implementation and monitoring section officers as opposed to work taking account of the very many issues we had raised.

When Ms West got to see the 59-page report that was being referred to at the meeting of the Policing Authority, what was her response?

Ms Lois West

It is fair to say I was aghast. As Ms Galligan said in her statement, I immediately felt disgust. I felt it was quite insulting. To my mind, it was a very clear attempt to undermine the analysis that had been done and to take away from it, perhaps. I was deeply unhappy.

Was Ms West put under pressure to sign off on the 59-page report that had been referred to the Policing Authority?

Ms Lois West

When the 59-page report was handed to me, which was at 12.20 p.m. on the afternoon of 8 May, it was conveyed to me that views were required on it by the end of the day. I said I would try to provide views but, on looking at it, it was simply not possible and we really needed time to compare and contrast it with the original 2016 report. I felt very aggrieved about the wording of the report and the insinuations in it that Ms Galligan's methodology was inherently weak, confined or inappropriate. I really felt it was only fair that we should be given the opportunity to respond appropriately to that criticism.

Do I take it from that that there was pressure put on Ms West to get her agreement to sign off on the report?

Ms Lois West

There absolutely was pressure to sign off. It was primarily in regard to the 41 cases that there was pressure to agree that everything was fine and that nothing needed to change.

There was another Policing Authority meeting on 29 June 2017. Was Ms West happy with what was presented to the authority on that occasion?

Ms Lois West


What made Ms West unhappy with that presentation?

Ms Lois West

There were a number of references to difficulties and issues that there had been, and an impression given that the database had been rectified. We had concerns because we had not been asked to conduct any checks to verify that and because we had felt a little excluded, we were not necessarily sure about what work was going on behind the scenes. We felt the need to check and verify that. We also knew at that time that we were not satisfied because there was still no agreement in relation to the 41 cases.

There was a further Policing Authority meeting on 28 September 2017. I watched it and there was a brief reference to the homicide review and report. It was confirmed to the chairwoman of the authority that the investigative side of the house and the analysis side of the house had signed off on it. Was that correct at that stage?

Ms Lois West

Yes, in relation to the classifications. As of mid-September, that particular issue had been resolved.

Ultimately, although between December 2016 and September 2017, as Ms West said earlier, PDIM and the investigative side of the house were not adoptive of the findings of Ms Galligan and Ms West, they changed their mind and said the analysis service was right. Is that correct?

Ms Lois West

That would appear to be the case, yes.

How stands the homicide review from the point of view of the public? When will it be completed? Is the analysis service's methodology being adopted for the purpose of the review?

Ms Lois West

Yes, it would now appear that Ms Galligan's methodology will be the cornerstone of this. I have concerns about trying to set timeframes for this and I absolutely understand the public concern. That is why Ms Galligan and I have been pushing for the past 15 months to get this work done but Ms Galligan has a particular expertise. She is the only person who can do certain elements of this work and she will also be required to sit as part of the review team to debate the classifications of these cases. We are committed to being part of the peer review and to the investigations. There is only so much that one person can do in the working day, regardless of how diligent and conscientious he or she is. It will take time.

As Dr. Singh alluded to a few weeks ago, we are not necessarily in control of everything ourselves. We are dependent on availability within the OSP for a workspace for Ms Galligan in order that she does not impact on its day-to-day work. We have to be cognisant and consider that we are dependent on other agencies on well.

While senior management has come full circle and recognised that the analysis service's methodology is correct, significant time has been lost conducting the review. Is it correct that this is the upset of it all?

Ms Lois West

That is of great upset to us. We have pushed for this and considerable time has been lost. Now of course there is considerable pressure on us to turn this around quickly.

Ms Galligan conducted the empirical research. In her statement, she raised an incident of serious concern upon discovering the partner of a deceased person was in a new domestic violent relationship. Does that illustrate the danger of not having up-to-date and accurate data, given one cannot follow the history of an individual who may be engaged in domestic violence?

Ms Laura Galligan

Very much so. If the incident is not recorded correctly, there is no way that we can analyse or predict any escalation of a domestic violent relationship. One of the reasons for the domestic homicide review was to identify whether there are trends in the escalation or whether they are lone events. However, if it not recorded correctly on PULSE, there is no way for us to analyse other than to go through everything incident by incident. That is what I was doing. I would go in, look at an incident and keep going back manually. It is a time-consuming exercise.

It is damaging for victims that the information is available. In fairness to members of An Garda Síochána, it makes their lives much more difficult when it comes to investigating potential crimes because they do not have the raw data.

Ms Laura Galligan

If there is a potential chance that we could prevent a domestic homicide, as an organisation, we should strive towards that. If we recognise that a partner in a previous domestic violent relationship is in a new domestic violent relationship, we should be able to offer support and services to that victim in order that we could, hopefully, prevent further incidents and, in the worst case, a homicide from happening.

Sitting suspended at 10.45 a.m. and resumed at 11 a.m.

We will resume in public session. I invite the next member to engage with our witnesses. I call Deputy Donnchadh Ó Laoghaire.

I thank Ms West and Ms Galligan. Everything connected with this is of enormous public interest, whether it relates to the seriousness of the crime, the ability of the public to have full faith in reporting such serious crime and how this has been managed. Another is how it has been presented by An Garda Síochána, which is something about which I continue to be concerned. I want to pay particular tribute to our witnesses, as clearly enormous pressure and stress was placed on them and I am grateful to them for coming before the committee.

Ms West's statement referred to a phone call on 12 May. At this committee's last meeting which discussed this issue with Garda management, there was much discussion about the April meeting of the Policing Authority. That is significant because it was the first time that this was properly discussed in a public forum. On that occasion the impression was falsely given that An Garda Síochána as a whole was satisfied with the report, as was the review group. Ms West has since put on the record that that was not the case, as did Dr. Singh some weeks ago. However, the explanation given to the committee at that meeting three weeks ago was very much to the effect that it was something of an oversight. In this regard, Mr. Michael Finn remarked:

I accept that concerns were raised about this. In the report presented to the Policing Authority in April somebody had reviewed the investigations and clarified that an investigation had been carried out in each of the 41 incidents. The error, however, was made in that we did not sit down with the analysts and raise or surface the issue of whether the investigations had all been properly classified.

To a great extent it was presented as an error or oversight. In the context of this phone call, it is quite clear that the concerns which Ms West and Ms Galligan raised in their report had been discussed among senior garda personnel at a meeting on 13 April, prior to that meeting. In that context, do the witnesses think it is credible that it was simply an oversight that they themselves were not consulted prior to the report being presented to the policing authority?

Ms Lois West

I am not sure I could conclude that it was just an oversight. I can only go by what I have been told and looking at it through my lens, but I would find it difficult to believe that.

Some of the most senior garda personnel were aware of the witnesses' very serious concerns and many of those personnel were the same personnel who would have been at the Policing Authority meeting which stated that this report had been signed off, is that correct?

Ms Lois West

On 11 April 2017, a request came in, request No. 210, from the Policing Authority, which sought further information relating to the homicide review. It followed on from some media coverage on 1 April which had created an interest in the review. Ms Galligan was in a meeting that morning, so I pulled together some of the documentation we already had. It was all at a very high level with no case-sensitive information; we never would have discussed case-sensitive information outside of the appropriate forums. I included some more up-to-date information about where we were in the review and did a synopsis of the very high-level data quality issues we were finding. The Policing Authority had requested that report by return on 11 April so I dutifully did the report and sent it up through the chain of command. The next day I queried whether the report had gone and was told that it had not gone yet but it would go now. There is a Policing Authority liaison office through which everything destined for the authority goes. That is for the necessary protections in relation to data, freedom of information and so on. I had no real reason subsequent to that to think that the report would not have gone to the Policing Authority.

There seemed to be some concern over that report. I am not sure what the concerns were. My understanding would be that there was perhaps a pre-meeting on 12 April to a private Policing Authority meeting that was due on 13 April. My understanding was that both of the reports were discussed at that pre-meeting. However, I was not present and could not say anything further about what decisions were taken or why.

While Ms West was not present, would it have been the case that the meeting would have involved some of the same personnel that would have represented An Garda Síochána at the Policing Authority meeting in April?

Ms Lois West

I would think so, yes.

The next public meeting of the Policing Authority took place on 29 June. At that stage, it was informed that the report was close to conclusion, and once again, gave no impression that there was anything untoward and that everything was progressing. Would Ms West agree with that characterisation that the report was close to conclusion then? What would Ms West's analysis of the report's status have been at that time?

Ms Lois West

I think things were still were probably still very much up in the air for us. Our stance was always firm that it would not be acceptable to draw a conclusion that there was nothing wrong or that there were minor issues in classification. As far as we were concerned, when that 29 June meeting was ongoing, nothing had changed.

I have some questions arising from Ms Galligan's statement. The 87 page report from November 2016 outlined four areas for concern, of which one stands out. As Ms Galligan put it in her statement there were "deaths that the cause of death deemed it suspicious and the Garda investigation would ascertain whether criminality was involved or not, yet these were recorded in a non-crime category or no category at all". Later in her statement, Ms Galligan referred to an email relating to her May 2017 report in which she wrote:

The deceased victims have not been given the respect and duty of investigation into their deaths that they deserve.

Later on, she wrote:

However, I cannot continue to identify incidents of homicide as we continue in 2017 that are not recorded correctly or not knowing whether there is an adequate investigation being carried out into that person’s death.

One of the biggest areas of concern is whether among all the potentially misclassified cases are a number of homicides that were not properly investigated. That would be the biggest concern for any member of the public listening to this today. In Ms Galligan's statement, that possibility is raised twice. Is there a possibility in Ms Galligan's mind that there are families who have lost a loved one who may have died through homicide, who may not be aware of that?

Ms Laura Galligan

I cannot comment specifically on that point. When I look at the classification and see that homicides are misclassified as non-crime or non-fatal incidents, I question why they are classified as such. An interpretation of the crime counting rules would say that if investigators have a reasonable probability that they have a homicide, then a homicide investigation is usually initiated and should be recorded as a homicide.

Obviously, we have not seen the investigation files in any of the 41 cases, although going forward we will be part of the review team, but it is important that we see the files from an analytical point of view in order that we can give our expert view on them. We never claim to be investigators. We raised the issue because the issue was there with the classification, which would also raise concerns as regards the investigation.

Ms Galligan said deceased victims have not been given the respect and duty of investigation into their deaths that they deserve. She also said the State Pathologist was summoned to a number of homicide incidents. Is she of the view that at the very least, the indications are that not everything was properly followed up in the investigation file?

Ms Laura Galligan

Every year the OSP gets referred cases from hospital pathologists, which require forensic pathologists. I question how they were dealt with at the scene. They were looked on as a natural death as opposed to a suspicious death and the body was transferred to a hospital but the hospital pathologist said the State Pathologist was required. These are the cases.

From the point of view of an investigation, are there significant risks in that?

Ms Laura Galligan

I cannot comment on the investigation point of view because I do not see the investigation files.

I refer to Ms West's statement. She said: "As it transpired, there was an apparent reluctance to countenance many of the issues we tried to raise and we made many attempts to highlight the potential organisational risks, the inconsistencies we were identifying and the absolute need to review the approach to death classification and investigation, not only within An Garda Síochána but in collaboration with partner agencies". Could she comment on the reluctance she describes? Does she believe the reluctance was grounded in a fear of reputational risk to An Garda Síochána? What was the basis for the reluctance?

Ms Lois West

Again, if it tried to give an answer to that, it would be purely speculative so I will avoid that. However, regarding why we felt there was a reluctance, every time we tried to introduce a reference to a particular case from outside of the three-year sample period, we were shouted down and we were not permitted to bring those cases into consideration. I do not want to go into the specifics because I do not want to allude to particular cases but there were certain conversations around policy matters, for example. A policy cannot be written on the basis of a sample review. That would be short-sighted because there are nuances in each investigation and there can be differences. If one writes a policy that suits a particular group of incidents, it may not suit others. When one is doing something as important as writing policy, it is important that one is cognisant of all the variables when doing that. It felt at times that there was pressure to rewrite policy there and then as if Ms Galligan and I were the people who had the difficulty with the policy and, therefore, it was incumbent on us to say how we wanted it worded. This was never about Ms Galligan and I; this was about the concerns we had in relation to public confidence and reputational damage. We never at any stage wanted any of it to be personal; we just wanted to try to resolve the issues. It was of concern of us when we felt that we were not being allowed to raise pertinent issues.

During our previous meeting with An Garda Síochána, Dr. Singh was asked whether any pressure was brought to bear on him not to question the report that was referred to at the Policing Authority meeting in April 2017 and he stated on a number of occasions, "Not that I am aware of". However, Ms West has detailed clearly in what is the same report essentially that between 8 and 10 May, she felt significant pressure was brought to bear on her to sign off on the report. She stated that professionally she could not sign off on the report and that she made that clear. It seems there is something here, which might not quite be a discrepancy. If pressure was brought to bear on her, it is difficult to imagine that pressure was not brought to bear on Dr. Singh. In what way did the pressure manifest itself? Was it a series of phone calls and emails saying that the report needs to be signed off by a certain time and that needs to be the end of it?

Ms Lois West

That was a particularly significant three-day period. There seemed to be meetings ongoing that neither Ms Galligan nor I was present at, yet other members of the review team were. I took a little umbrage at that because I did not feel that that was equitable or that we were being given the opportunity to properly represent our views. Whether pressure was brought to bear during those meetings at which I was not present, I can only go by what I have been told or comments that have been made to me. Other people were present at the meetings on 9 and 10 May and pressure was certainly brought to bear on us. It is for others to answer whether they felt that. We were the key actors in the homicide review. It was critical that the understanding of the Policing Authority was that it had to come back as joint sign-off and, therefore, it was of particular import that Ms Galligan and I agreed to sign off.

Was Dr. Singh aware that Ms West and Ms Galligan felt under pressure? Did they make that apparent?

Ms Lois West


Was Ms West satisfied that her management both within the analysis service and An Garda Síochána dealt with her concerns adequately and that they were escalated adequately, particularly the analysis service?

Ms Lois West

No, I do not believe they were. The fact that Ms Galligan and I are sitting here today was not a decision that we took lightly but we felt that throughout the past 15 months, our views were not taken seriously enough. When we made particular personal representations because of a concern about lack of progress, we would see a small period of activity thereafter, including a number of meetings and so on, but that never tended to last. They still did not get traction which was of great concern to me and that is why at certain times we tried to bring others into the equation to give us that little bit of support that we felt we required to get the key messages across, understood and dealt with.

According to Ms West, ultimately, in September 2017, there was an acceptance that her methodology and approach was correct. Since that date, has there been an improvement in her experience or does she still feel insufficient priority is being given to the review and that she and her work have been treated with adequate respect and importance?

Ms Lois West

To be completely honest, it is only in the past number of weeks that it is receiving the attention that it should. We sent an email on 11 December seeking a meeting with senior Garda management because of our ongoing concerns about the lack of progress. We again saw a small flurry of activity afterwards and it was possibly on foot of this that another senior member of An Garda Síochána was appointed to lead a new working group. With Christmas and so on, it was 5 January before the group first met. We raised concerns after that meeting. We still felt that there was no clear direction. We always recognised how expansive an issue it was, that there were various elements to the work that needed to occur, and that it was important that the work was sequenced in such a fashion that certain parts did not cut across others.

We were aware that a multi-agency working group was to be set up, but it still has not been set up. My concern would be how the two groups would interrelate so that one would not overlap on the other and if there were to be any impacts from one to the other, we would need to have very clear terms of reference for both.

We met properly with the new review team on 19 February 2018. I feel much more reassured. I feel there is a genuine appetite to involve us at every stage and that matters will not be signed off on, unless we have said that we are happy also. Perhaps we are about to get what we have been asking for from day one, which was a full and independent review of death and homicide classifications.

On foot of that, am I correct that the process Ms West has described is one and the same as the consolidated process that was announced by the Policing Authority or is that separate?

Ms Lois West

We were not involved in the meetings with the Policing Authority at any stage, in spite of asking to be involved on at least a couple of occasions. The Policing Authority has issued three specific requests, first, a review of 2003 to 2017; that is completed, which was always our intention; second, dip sampling of the court outcomes from the higher courts to see the reliability of that; third-----

Ms Laura Galligan

An independent peer review into the four year old deaths.

Ms Lois West

From my point of view, aside from the dip sampling of the court outcomes, we had been asking for the other measures since January 2017. Obviously we do not have the clout the Policing Authority would have, but I would have a concern that when people who have particular expertise and professional backgrounds who have been recruited into the organisation and are paid from the public purse have pointed at and have evidence that others in the organisation have issues that need to be addressed, they are not listened to.

I am close to concluding, but Ms West has raised a crucial point in how we restore confidence in the process. An independent peer review is absolutely crucial because one of the flaws the Policing Authority identified in the investigative side of the review was that the same people who were involved in the initial investigation were asked to review it again. That is far from ideal in terms of a process. My understanding is that this review will be carried out independently.

Is it the case that the overall review will continue under the auspices of the Garda Síochána but with the peer review to be conducted independently or is the entire process to be steered by an independent person?

Ms Lois West

There are several different elements to it. What we were always dissatisfied with was exactly what the Deputy has stated, that the original people involved in the investigations were initially contacted by phone and asked if everything was OK with the investigation. When the second attempt at a review was undertaken, I understand that they were written to and that the chief in the division had to sign off on the response that was coming back. That did not satisfy us because we would have the same concerns as the committee and others that Garda were looking at other Garda members' investigations and not actually reviewing the investigation files. Yes, there was certain information that was collected and looked at, which we did not see, so we cannot comment on that. From our point of view we always felt that it had to be a full and independent review. Ideally I would have liked external senior investigating officers from another force or from somewhere else that would do that job, but we do not have that easily at our disposal.

We have met the new review team and they are in regular contact and are engaging with us. I have no reason to lack confidence in that. Ms Galligan and I have entered into every single one of these review processes enthusiastically and in good faith. We will absolutely do the same on this occasion. My main concern would be how we take on the level of work that will be required in respect of other demands and in particular the amount of work Ms Galligan will be required to do because of her expertise. I think we have to manage the timeframes and the expectations realistically.

I have two other questions. Is it possible to quantify the misclassification of the data that can be put down to weaknesses with PULSE, human error or other factors? Could Ms West give an indication as to the origin of the misclassification?

We need to focus on how we move on from this point. In addition to the review continuing and reaching a conclusion, what should the committee, the Policing Authority and An Garda Síochána be doing to rectify the matter and to ensure it is not repeated?

Ms Laura Galligan

As regards the classification issue, as part of the review process, there will be somebody assigned to actually go back and audit when it was changed, why it was changed and the reason for the delay in the recording of it correctly. That will be part of it. It will be in the end report of every single death that will be reviewed the reason that it was misclassified incorrectly - whether it was human error, the limitation of PULSE, or whatever reason.

Ms Lois West

I think there would be a variety of different reasons, it would not be possible today to try to quantify it. One can see where there would be debates about the classification of an incident, some would be more in a grey area and could be difficulty to determine straight away. I think part of the difficulty has been that PULSE is seen as optional at times, or it is one of the last things to be considered.

As an investigation progresses, obviously everybody involved in that investigation is extremely busy and it has been felt at times, there has been more of a slack attitude towards updating PULSE, that it has been seen as less important than other aspects. There certainly seems to be that misunderstanding around the crime classification. Ms Galligan and I did work in September with members of PDIM, the policy development, implementation and monitoring, group to put together a more comprehensive clarification of the crime counting rules to try to make the interpretation of them much clearer and easier to follow, so that everybody would be consistently applying the same logic. There are very many elements to it. As Ms Galligan said they will be looked at in the round as part of the new review.

In terms of moving it forward, we will fully support it. There is quite a significant team that has been put together. We have high hopes for that team but one of the things that would be important for me is to address the fact that sometimes An Garda Síochána feels that it has to resolve all the issues on its own and is not very good at asking for help or saying when it does not have adequate resources. There is a culture of making do. There is a great can do attitude. Fantastic work goes on in An Garda Síochána and a lot of that is down to the goodwill of the people who work there and their determination to work very hard to serve the public and to do the best they can, but at times we need to ask for help, whether that is money, external expertise or assistance from other agencies, even others within the Department of Justice and Equality. It can take more than just one body to resolve a particular issue.

I thank Deputy Ó Laoghaire. I call Deputy Brophy.

I thank the witnesses for coming before us. I know they have covered a lot of ground with my colleagues so far. I have a couple of points I wish to touch on, and I will try not to go over issues that have been dealt with already.

My first question is more relevant to Ms West who has been working with An Garda Síochána for ten years.

What the witnesses have described of this sequence of events to us is very disturbing. Is this a completely isolated incident in Ms West's ten years working with An Garda Síochána or is it part of any pattern or any previous incidents of a similar nature with which she is familiar?

Ms Lois West

I have been working with An Garda Síochána for nearly 11 years. When we had the first analysts in in 2008 we hit the ground running. We have done some exceptional work right from the beginning. The analysts and the management team in GSAS have always raised a concern about the quality of the data with which we had to work. When analysts produced a report, they tended to put a section into it outlining the particular data quality issues that were hampering their ability to do a complete and robust analysis. We have also found that the analysts frequently have to do quite a lot of data cleansing to make the data as workable as possible, which is far from ideal because it is very time-consuming and takes away from the ability to actually do the work. These concerns have always been raised in these reports, many of which ultimately ended up with senior Garda management, and this issue has been discussed along the way. I feel there have been many occasions on which we have escalated reports and they may not have got the requisite attention. That said, I would make a qualification. We have an exceptionally good working relationship for the most part with the officers within An Garda Síochána. Exceptional support is given to operational work and particular investigations, and we do a lot of work to feed into the formulation of strategies and so on in so far as we can. For me, this has polarised things quite a lot. What has happened in this instance is fairly exceptional. Previous to this, it was perhaps a failure to fully address issues that was raised in reports. This, to me, feels like probably a little more than that.

I fully appreciate what Ms West has said. I appreciate and echo her sentiments that there are many excellent officers in An Garda Síochána who work above and beyond the call of duty to ensure the Garda delivers on solving crime and in its day-to-day work. However, I want to go back to the other part of what Ms West said. It strikes me, listening to the answer she gave - and I do not want to put words into her mouth - that there was effectively a systematic way of disregarding information on the part of management in An Garda Síochána over these years in that it escalated a matter if it did not like it. Unfortunately for these members, they got caught this time around in that there are new structures in place - the Policing Authority, etc. - which meant it was not possible for them just to take the stuff and ignore what the analysts were saying. This incident escalated out of that. They had to effectively cut the witnesses out of the reporting loop. Is that a fair assessment?

Ms Lois West

That is the Deputy's assessment. I do not really want to be drawn to comment that far. Analysis was new to An Garda Síochána ten years ago. There probably was a lack of familiarity with analytical product and what should be done with it on receipt of it. Therefore, there has been a learning curve over that ten year period, during which officers have become very familiar with our analytical reports and monthly reporting and the various ways in which we can support investigations. We have also supported the senior investigating officer and detective sergeant training courses. I think there is a better understanding of what analysts can bring, but at the same time it has felt like an uphill battle at times when one is trying to draw to the attention of senior Garda management that there are particular issues and one does not seem to gain the traction one would hope for.

Just as a comment, rather than a question, to Ms West, I think over a ten year learning curve many of what were the very senior Garda officers recently would have been in the lower ranks, learning, I hope, before they got to their very senior ranks. I want to link the witnesses to this to bring the meeting up to this particular sequence of meetings we are going through. There seems to me to be a problem with the civilian interaction with members of An Garda Síochána. When Ms West talks about the fact that in this sequence of events there were meetings to review that she was not at, would it be fair to say that all the other people present in those meetings were probably serving Garda officers?

Ms Lois West

I think there were probably certain meetings at which GSAS management was represented. My concern is that Ms Galligan and I were really the key actors in this whole homicide review, and to me it felt like an omission that we would not be involved in the meetings. Certainly, the sworn members would have been in the majority.

Therefore, if it was not just serving Garda officers, would the witnesses' effective boss be the person present at those meetings?

Ms Lois West


These were the meetings that the witnesses felt they were excluded from that looked at the matter.

Ms Lois West

Some of them, yes.

I will move on to one aspect of this that I cannot fully understand. I raised it at our last meeting. If the meeting of the Policing Authority took place on 27 April, why did it take until 8 May for a request that this unsatisfactory report be commented on? Dr. Singh said to me, when I asked him about this, that he tried to get the report. I am totally confused as to how something can be given to the Policing Authority at a meeting at which the witnesses were present and it takes from 27 April until 8 May for a copy of it to be made available. Do the witnesses have any indication as to why they were not furnished, on the day of 27 April or on any immediate subsequent day, with the full report?

Ms Lois West

I really could not be sure. It was a surprise to us when we heard on 27 April that such a report existed. I know that Dr. Singh asked for it, I believe on 12 April and again on the morning of the Policing Authority meeting of 27 April. I am not sure why it was not forthcoming to us until 8 May, but certainly when we first looked at it I could imagine that there may not have been an appetite to share it with us.

Ms West therefore thinks it was a deliberate decision, even after it had been presented to the Policing Authority, not to share it with her and Ms Galligan.

Ms Lois West

I am still not entirely clear exactly what the Policing Authority got in advance of that meeting on 27 April. I am not sure if it was given the full report as we got it on 8 May or if it was just a redacted, sanitised table of incidents, so I am not clear if this report actually went to the authority. Certainly the report that was presented to us on 8 May was deeply concerning to us.

This ties into the other area I want to go into. The witnesses have raised a very interesting new area today. The Policing Authority's actions in this case seem to me to be very interesting. There was a meeting on 27 April. My understanding and calculations of the various dates - if I am wrong, I ask the witnesses to correct me - is that Ms West made one direct appeal to the Policing Authority prior to that meeting of 27 April to discuss this issue with her or to take a phone call about it. Did Ms West actually speak to anyone? Was her call not returned? I am not being smart, but did she leave a voicemail message? How did that call go, and what did the Policing Authority do about that call prior to this meeting of 27 April?

Ms Lois West

The phone call I made was on 3 April. I spoke to a lady; I am not sure exactly who she was. I believe that a message was to be conveyed to a member of the Policing Authority that we were seeking to have a conversation about the homicide review. My understanding is that the request to meet was declined.

It is not just that the Policing Authority ignored it, then; it formally declined.

Ms Lois West

I believe so but I would not like to say with 100% certainty. I just know no meeting ever emerged as a result.

After the 27 April meeting of the Policing Authority - the witnesses already had one contact with it - they had this very unsatisfactory report, possible report or whatever. Reservations were expressed quite openly to that meeting by Dr. Singh, etc. The witnesses then made subsequent efforts to contact the Policing Authority; it had subsequent meetings before we got to the point of resolution in September. What was the tone of the contact by the Policing Authority to the witnesses or its attitude to them during that period regarding their effort to communicate with it?

Ms Lois West

The second phone call I made was on 16 May. It was very much the same as the first liaison, which was that I spoke to a lady. I believe there was a message conveyed and no meeting resulted. I had made contact at that stage because of my deep concerns over what had played out in the week to two weeks prior to that. As I noted in my statement, I had written a lengthy letter internally within the organisation on 11 May 2017. When I made that call on 16 May, I was quite surprised to hear that the letter had been seen by the authority. I could only conclude that it was my letter of 11 May, which I had not shared with the Policing Authority. That was an internal document, so I am not sure how it came into possession of that.

We then wrote a letter to the Policing Authority on 30 June, which was obviously the day after the 29 June public Policing Authority meeting. I suppose our frustration was escalating at that stage. We had ongoing concerns. We were not happy about how the meeting had played out on 29 June. We received a response to that letter on 12 July, which was really asking if the letter could be shared with Garda colleagues for their response. I understand, of course, everybody has to be able to give their explanation or reasons they said certain things. However, because we felt under pressure and that the workplace was not the best place to be, we did not want to complicate matters further for ourselves at that time. We then received an acknowledgement of the letter we sent on 19 July, declining at that time to share that letter. We offered to help the authority in any way we could. I suppose at that stage we probably felt that some protections would have to be offered to us if we were going to be exposed to Garda colleagues as it were. The acknowledgement we got back from 19 July was maybe a bit dismissive. The content was that it was noted with thanks.

Do the witnesses believe the Policing Authority let them down in how it dealt with them?

Ms Lois West


I wish to switch tack away from the Policing Authority to a completely different aspect of it. This relates more to Ms Galligan's area. A layperson listening to anything like this would be knocking their head against a wall wondering how a garda cannot know when a homicide is a homicide and how a classification can be so wrong. I appreciate Ms Galligan gave us some very detailed information and alluded to the fact that there can be certain grey ones. However, we seem to be way beyond the area of certain individual grey cases into just people not recording. In light of other ways in which the Garda has recorded figures, we get to this.

I know there is a review and the changes the witnesses have outlined. Is it fair to say that either the current PULSE system is structurally completely unsound for recording data or, as Ms Galligan also made reference to at one point, gardaí are not filling in fields - maybe choosing to leave them blank? What is at the heart of the mis-recording at an input level? Is it structurally completely inept and not working or is there just a laissez-faire attitude to actually inputting information or is it a combination?

Ms Laura Galligan

I suppose I cannot comment definitely. Culturally it has been that it was okay to record a suspicious death under a "sudden death" category, which is non-crime, until the investigation was well advanced. They may be awaiting the DPP to return either a homicide direction. They may then reclassify or they may forget to or whatever the case may be. I do not know why. There are grey areas where it is not as clear-cut at the beginning that a certain case is a homicide. There are some very grey areas. For example, if somebody has blunt-force trauma it could be accidental or it could be caused by a third party and an investigation will ascertain that. As regards why they do not fill in the fields, I cannot comment as to the reason.

Ms Lois West

Structurally there are issues with PULSE. We documented this in our 17 June report in the recommendations section. It is hard to understand why there would be 16 different ways to classify a death in PULSE. That will only add to confusion that members feel. For example, there is a "sudden death" category and a "dead body, no offence disclosed" category. That could nearly be seen as an optional choice. What is the difference? I am sure when they were devised and added to the system, there was a rationale. Over time the person who asked for that to be added is no longer there and others do not understand why it was added or what it was for.

A pattern can be seen where a particular division will be recording in a particular category that no other division really uses. Again that confuses the issue. From our point of view, one of the first things that needed to happen was an overhaul of PULSE - to refine that, to simplify and bring down the number of ways a death can be recorded. As Ms Galligan would say from her professional background, there should really only be four to five categories available for a member or someone in the information services centre to choose from. As I said earlier, there is a multitude of different reasons these things-----

I suppose that is what I am trying to clarify. It is not that there was necessarily a systematic attempt to somehow do it wrong. I would not like to define it as a mess, but it was effectively a mess in the way a senior guy was saying that this is the way it has been logged in here, so log it in that way. The whole process shows a complete lack of training and the structures that should be in place to run a proper system if people are going to rely on the data.

I will finish on the data. I am conscious that the witnesses have been here a long time and other colleagues want to come in. I wish to return to another aspect of those Policing Authority meetings. Allowing for what we know now and the sequence the witnesses have outlined, based on the evidence supplied about the reports to the Policing Authority - irrespective of whether there was an actual report - how would the witnesses define that evidence being given? Was it truthful evidence? Were the people supplying that information effectively misleading the Policing Authority either by accident or deliberately?

Ms Lois West

There certainly were misleading comments made. I would not like to comment on whether that was intentional or accidental. There certainly were robust debates. One of the ongoing debates was over whether it was acceptable to record something as a sudden death in the first instance until the Garda had conducted some kind of investigation to determine whether there were suspicious circumstances. To our mind there were clear instances where that simply could not be justified. There was a difference of opinion. I suggest that some of it may come down to a legacy issue - the way that people traditionally did something. That does not make it right. From our point of view it certainly would not be in adherence to the crime-counting rules.

The Deputy makes a very important about education and communication within the organisation. I have always expressed concern over headquarters directives, for example, where a new policy is pushed out through a headquarters directive or a particular instruction because it is not clear to me that there is enough support to ensure that every member or person who needs to be aware of that has read it, interpreted it correctly understood it and is then adhering to and applying it in the course of their duties.

I certainly would have a concern regarding the education piece.

My apologies as I also have to leave. I thank the witnesses for their answers and time today.

I thank the witnesses for coming before us. I know they must be worn out at this stage so I will try not to repeat what others have said. From the point of view of our job here, we have an obligation to oversee issues of Garda accountability and so on. When we bring people in to ask them questions, we must rely on their answers to a certain degree. The witnesses' information has been incredibly helpful to us in terms of challenging some answers we were previously given whereby we did not have the supporting information to say that those answers were not really evidence-based. Our job is to take what the witnesses have given us and bring it to the next stage. I just want to clarify, and it may be a bit eclectic, some of the background to some of this stuff and how we got here. The witnesses were basically asked to carry out a ten-year review of domestic homicides. Was it the witnesses' suggestion that they should start with a sample?

Ms Lois West


Ms Laura Galligan

I started the review with 2014 - not for any particular reason. It was just the year I began with. I immediately started identifying inaccuracies with the Office of the State Pathologist records, PULSE and our spreadsheets. I suggested working in collaboration with the Office of the State Pathologist because I knew its files are filled with information and background to the case. Immediately, I identified in 2014 a number of cases. I told Ms West by telephone. I was away on training abroad with An Garda Síochána. When I returned, I began dealing with cases from 2015. Ms West told me to stop it at three years as a sample period so we could raise this issue quite quickly with the Garda executive.

The service was looking at the PULSE and State Pathologist's records. Around November, Dr. Singh told us that it became apparent it could not produce a comprehensive report unless they saw the investigating files. He told us he asked in November to see the investigating files on behalf of the unit. To the best of the witnesses' knowledge, did he ask specifically for the files or in general? What was the response to that? Was that done?

Ms Lois West

I would not be sure. We were not there when the senior executive was briefed so we are not quite sure. We had always been seeking a full and independent review. Maybe there was a lack of clarity about what exactly we meant by that but it was always our view that just going back to the original district officer or the person in charge of an investigation was not satisfactory and some questions we raised would not be answered through that process. At that stage, our focus was very much on the classification of the incidents and trying to come to a consensus position. When we came into this, we were not reticent about raising the issues but we might have been lacking a bit of confidence. One always has that fear about whether one is right. We wanted some verification and that was the point of asking to work with others to try to come to that consensus view about whether or not there was an issue here. We were pretty confident there was an issue but we did not want to overstate the issue until we were sure that our feelings were correct.

I suppose there were a couple of things going on. Everybody's attention was focusing on that period and the 41 cases but another narrative was running alongside that, which I found particularly frightening. This related to ongoing concerns the witnesses were attempting to flag. They said one example involved a deceased person who had been a victim of domestic violence and whose partner was involved in another relationship marked by domestic violence. They said they subsequently highlighted a number of similar cases. They described how getting to that stage was like stitching together a patchwork quilt. From reading that, I conclude that there were people in 2017 who were in danger because of incomplete data. I put this matter to Assistant Commissioner Finn on the previous occasion on which he was before the committee in terms of that situation and the review that was ongoing. I specifically asked him whether in the cases of domestic violence death, other incidents of domestic violence on the person's file would be analysed in case there was a missing link so a sign that had been flagged could lead to something being averted. He told us that new processes were in place. I think he said that when Dr. Singh and his team look at the data on domestic violence, they would find that crimes had been classified correctly from the start. My first question is whether the witnesses found that domestic violence incidents have been correctly classified from the start. Second, do the witnesses know anything about these new processes Assistant Commissioner Finn told us are in place that will alert the user if the person has been involved in a previous domestic violence incident relating to the person in place?

Ms Laura Galligan

I can answer the first part with regard to the analysis I have already done. I assure members that I will go back in any instance with the victim in the lead-up to every domestic homicide I will be reviewing - be it months or years. I would have questions about whether they have been recorded correctly. I have come across incidents that I do not believe were recorded correctly, for example, when they were recorded in attention and complaints when they should have been as a domestic incident. I am not up to date regarding what the up-to-date policy is and whether they informed that a previous incident occurred.

Based on the evidence and analysis of the files looked by the service so far, is it fair to ask whether the witnesses believe - and I know it is only a belief but it is based on analysis and data - that people are at risk today because of crimes being misclassified on PULSE or risk indicators being missed?

Ms Lois West

I do not think it is overstating it. We do not want to cause people panic either but I would suggest that Assistant Commissioner Finn was referring to the victim screen. A lot of work has been done there in respect of technical fixes to PULSE in order to make the data collection better. When an incident is recorded now, a victim screen will come up and that will be populated with the detail of the injured party. I do not think a system exists where it would necessarily flag up when a member or someone in Castlebar went to create an incident. I do not think any big flag that this has happened before comes up. We are dependent on the incident being recorded correctly. We have "attention and complaints" and "domestic dispute with no offence disclosed" categories. That domestic dispute with no offence disclosed category was very much created to capture where An Garda Síochána is asked to respond to a house because there are reports of a disturbance and gardaí get there and do not find anything but can go in and record the fact that they were called out. I understand that the victim screen becomes active with domestic dispute with no offence disclosed incidents. Of course, it would become active if it involved an assault or crime incident as well. Our difficulty is that there has been a tendency, which I believe to be ongoing, to put some of these incidents in the attention and complaints category. Therefore, a victim screen would not be activated for that incident. One could understand how a member would still be recording a call-out to a property as an attention and complaints incident if the awareness is not there of domestic dispute with no offence disclosed. The victim screen is fairly recent so there would not be that history going back for people who have already been victims of domestic abuse or violence.

Again, we come back to the motivating factor as well. What is supposed to happen if someone is the victim of an assault, be it minor or an assault causing harm? A box should be ticked to say that this was a domestic incident. That is the easiest way for us to identify that an incident is of a domestic nature. Otherwise, we are trawling narratives for many hundreds of assaults in order to try to work out if there is even sufficient detail in the narrative to tell us whether it is a domestic incident.

I still lack confidence in it. Over time, there have been technical fixes and attempts to put various fixes in place to assist the process but it is still not a complete process. It is still not one that lends itself to easily identifying an escalation of incidents or people who may be vulnerable. Ms Galligan has done the best she can in the work she is doing and has liaised very closely with the Garda national protective services bureau. We referred any cases that Ms Galligan raised as potentially concerning to it. We felt this was the way they would get the attention they required because that national unit would be able to contact the region, division or district and ensure there was proper attention given which would assist with the proper supports being in place for the vulnerable person.

Some of the concern is that the witnesses flagged this internally in the organisation. They were essentially saying that because of it there were people who were potentially in danger in 2017 and possibly 2018. It is my understanding that the people in PDIM told the witnesses not to give it to them and that they did not want to read it because it was not their job. Was it anybody's job?

Ms Laura Galligan

I liaised directly with the Garda national protective services bureau, with both the chief superintendent and the two detective superintendents, and on an ongoing basis they are very welcoming to any cases I spot. When I highlight a case they implement action on them quite quickly. I do not have time to trawl through PULSE on an ongoing basis trying to identify cases when I am supposed to be doing many other jobs. That is what the issue is.

The review being undertaken at the moment will look at missed flags. Will it look at complaints that may have ended up categorised as "attention and complaint", which were not appropriately categorised?

Ms Laura Galligan

Every domestic homicide incident recorded on PULSE whether it concerns a victim or witness will be looked at to see whether it in any way impacted on or contributed to the person's death.

There was a point made in one of the submissions that the witnesses were under the assumption that it would go to the Garda professional standards unit for monitoring but it did not at the time. Has this work ever gone to that unit?

Ms Lois West

I do not believe so. We will certainly endeavour to do the best we can. The difficulty we have is we are starting with a domestic homicide and working back to look at the history. I would not like to sit here and give any guarantees we will be able to pick up on every attention and complaint incident that was potentially a domestic incident. The system is vast and there are a huge number of records in it.

The point of beginning with a victim and working back is to be able to make certain recommendations and inform intervention strategies. It will take time to do it. Part of the reason it has been disappointing that we did not have the traction we wanted sooner is because we have lost time. Our aim is to try to professionalise and standardise everything and to try to ensure there is consistency. I will hark back to what I said earlier. I have concerns about the structure of posts; the education of members and their understanding of the various crime and non-crime classifications; and the ability of the data quality unit within the Garda information services centre, GISC, to be able to identify where something has been misclassified. In the course of this year it is intended that the Garda information services centre will be responsible for determining the classification of incidents. We should get away from the issue we have had where there is a debate about what the incident is between the member and the person in the information services centre inputting the incident. I hope that if a member makes contact with GISC and says he or she wants to record an incident as "attention and complaint" but it is clear to the person taking the call that it is actually a domestic assault, it will go in as a domestic assault.

In terms of the PDIM group that was set up and the nine meetings that were had, who was the highest level member there? Did an assistant commissioner sit in on it? What was the highest rank at it?

Ms Lois West

The assistant commissioner was not at any of the nine meetings. The chief superintendent was the highest rank at it.

Assistant commissioners changed in the middle of the project. On the hit-and-runs, the point made in the presentation was absolutely incredible. PULSE does not have a hit-and-run category. Has anything been done to change that since then? Has it been corrected?

Ms Laura Galligan

There is ongoing work in the Garda national traffic bureau. They are looking at a lot of incident types, the data quality fields and things like that and improvements are being made. Fatal hit-and-runs are referred to the Office of the State Pathologist so I was picking up on them and saying it is a crime if one leaves a scene or if it is a case of dangerous driving causing death. From the moment the person is found, a crime investigation is initiated but it is being recorded under a non-crime incident type of "traffic-fatal" and there is no identifiable parameter to say it was a hit-and-run unless it was recorded in the narrative. I was concerned by that.

I am trying to get my head around the new working group and the new review. Deputy O'Callaghan made the point that the Garda side accepted that the witnesses' methodology was right and has come around to their way of thinking. Based on what Dr. Singh told us, the witnesses wanted to look at the investigation files in order to do a proper analysis but they are still not getting them.

Ms Lois West

We will as part of this new review group.

The witnesses will get them.

Ms Lois West

Yes, we will have access to them.

Will the witnesses be on the peer review group?

Ms Lois West

The intention is the two of us are to sit on it full time but, as I said earlier, I am not clear how it will work with regard to my other demands as deputy head of analysis. That is where clear direction is lacking. While people may say I will be full time on this team and not to worry about my other role, in reality that is not how it works. We can put Ms Galligan on to the group full time while recognising she has some obligations in court proceedings and so on but we will do whatever we can to support the work. The group has absolutely agreed that we will see everything.

I have a number of final points. I will refer to the Policing Authority and some of the points that Deputy Brophy and others made. Ms West made a phone call on 3 April saying she was assistant head of the analysis unit and that there was something coming up that she would like to talk to somebody about. That was effectively the content of the call that was made.

Ms Lois West


We regularly contact the Policing Authority as well and I am confident the message was given to the relevant people. Did Ms West hear anything back?

Ms Lois West

I got a call back later in the day declining to meet and saying it would not happen at that stage. We did not speak to anybody in the Policing Authority.

The message made it was clear who Ms West was-----

Ms Lois West


-----and the purpose of her call and that it related to concerns.

Ms Lois West


It was in advance. Despite the missing report, which the Garda never gave to the Policing Authority or which something happened to so it never went to the Policing Authority, the Policing Authority was aware in advance of the April meeting that when the gardaí publicly gave information to it that the report was from the team in the analysis service and the ordinary gardaí in it, it was in direct possession of knowledge that it was not the case.

Ms Lois West

Yes, it would seem so. If the message was conveyed, which I believe it was, then it knew of our concerns.

Based on my experience with it, I am very sure the message was relayed. We put it to An Garda Síochána that it gave information to the Policing Authority that was probably not correct. It is also true to say that the Policing Authority knew that when the information was given. That is something we will take up with it when it comes back to us after the recess. I was a little bit confused about the phone call on 16 May. Somebody told Ms West that he or she had a copy of her 11 May letter which went to the Garda executive.

Ms Lois West

That is how I interpreted what was said. The lady I spoke to on the phone, and I am not clear what her role was-----

Was this on 16 May?

Ms Lois West

Yes. A comment was made during that conversation that they had seen my letter. I can only conclude that it was the 11 May letter because there was not any other letter at that stage.

Had Ms West sent a letter to them?

Ms Lois West


For the purpose of accuracy, Ms West had sent a five-page letter to senior Garda management. I assume that went to the Garda executive.

Ms Lois West

It was the Garda executive, two assistant commissioners, the head of analysis and Ms Galligan, for her own records.

Two assistant commissioners, Dr. Singh, and the data analysis unit.

Ms Lois West

Just Ms Galligan in the unit because she was so involved, and so she was aware of the letter and what was in it.

Two assistant commissioners and the Garda executive received that letter - and it is interesting that the Policing Authority got it also. Other than the acknowledgment on 19 July saying "Thanks but no thanks" from the Policing Authority, there was no actual written-----

Ms Lois West

There were two letters from them. We received the response to the 30 June letter, which asked if the letter could be shared with Garda colleagues for their responses. We wrote back in July to decline and say it would not be pertinent at that time. We then received an acknowledgement, noted with thanks.

Okay. Ms West was told on 1 August by a member of Garda management that the Policing Authority was aware of her approaches and so on. Did Ms West find this strange?

Ms Lois West

That was in the context of a management meeting I was part of. It was raised with me as part of a wider management meeting. Obviously, there were not many people present but I was immediately concerned. To be honest I felt quite compromised. I absolutely understand that there are governance structures and that people are very wary of sharing data, as are we. We have been the souls of discretion in protecting data and case-specific information. I felt it was a breach of trust and a compromise. Where we had been trying to raise the issues and do what we felt was right to try to get the truthful message to enable the authority to be able to craft and ask pertinent questions at meetings, not only was our voice not being heard, they kind of told tales on us.

That is exactly the note I have written down for myself; essentially it was telling tales. Someone in the Policing Authority had taken it upon themselves to not telephone Ms West - she has never received any telephone calls from the Policing Authority - but to telephone someone in Garda management to tell tales on Ms West along the lines "Do you know that your assistant head of analysis has been on to us giving out about the Garda management and the report?". That is the first problem. The second problem is that the person to whom this was told felt bold enough to divulge that confidential information in the forum of an official management meeting to, albeit not in a public forum in the sense of a public meeting.

Ms Lois West

There were only two people present at the meeting and I was one of them. That person did feel able to raise it with me and ask what my thinking was in doing what I had done.

Was this Ms West and one other person, or was it Ms West and two others?

Ms Lois West

Myself and one other person.

Was it an official scheduled management meeting?

Ms Lois West

Yes. It was a morning meeting.

I thank Ms West for that.

I am sorry to interrupt Deputy Daly but for her information and that of other members we had indicated to the guests that we had hoped to finish by 12.30 p.m. I suggest that the session will run on until 12.45 p.m. There are four speakers remaining, including the Chairman, and I ask everyone to be mindful of that, to not be repetitious and to be as concise as possible.

My last point then is about the 12 May contact and the phone call received by Ms West. She discovered then that the information had not been passed on to the Policing Authority. The report had not been given. Nearly a month after Ms West had produced the report for the Policing Authority Ms West was told by telephone that the authority had not received it. Ms West offered that the committee could have the reports of that meeting. It would be helpful to have Ms West's notes of this conversation. This gets to the heart of this relationship between the Policing Authority and senior Garda management, which seems to be unravelling in a manner that the public would not expect. If it was possible then the notes would be very helpful.

My last point, for the record is-----

This is the Deputy's last question.

We know the organisation was in possession of Ms West's doubts and her very strong disagreement with the report furnished in her name. We know the organisation had that information when it went to the Policing Authority. Can Ms West say with certainty that the individuals who imparted that information publicly, at the Policing Authority in April and in June, had direct, personal knowledge of Ms West's disagreement? Does Ms West know the point I am making? Am I making it clear? We know that Ms West furnished reports where she could not say it any clearer: "I do not agree and I cannot sign off on this." Would the people who gave that information at the Policing Authority have been privy to that information directly? Ms West may or may not know this.

Ms Lois West

None of them was present at the nine meetings. We did not provide any personal briefing to a couple of the individuals who spoke at that meeting.

Ms Laura Galligan

By the June meeting - not the April meeting - we had both met with senior Garda management and aired our concerns about all of the issues we have discussed today.

There was the letter from 11 May.

Ms Laura Galligan

On 11 May we met them and-----

Prior to that it is not. Definitely for the June meeting that would have been, but for the April meeting the witnesses cannot say 100%. That is fair enough.

Ms Lois West

There would certainly have been knowledge among certain people on the panel that there was disagreement, but whether it was those people who spoke on the day I would not like to say with 100% certainty that the people who spoke knew of our strong disagreement. I could not really comment. We did not personally brief them.

Would the relationship between civilians and the uniformed gardaí be very different from what Ms West experienced in the PSNI?

Ms Lois West

Even in the PSNI there was a period of adjustment. The practice of civilian people coming in with particular expertise is a very new thing. The policing culture is a very strange one. It is like a family and anybody coming in as the in-law or whatever takes a little time to gain acceptance. There were difficulties there too but for the most part the analysts have been embraced and there has been a very good working relationship, even where we are considering very sensitive information. There are, certainly, occasions where there really is a difference, and this is highlighted. I will not go off on another tangent but it is particularly to be seen in industrial relations issues and different terms and conditions. None of these things helps. People need to feel that they are equally valued, not just in having their voices heard but also in the recognition and compensation for the work they do. It does not help and it creates a little bit of a them and us scenario when people do not feel they are on a level playing field.

I thank the witnesses. It has been incredibly helpful to the committee's work to have them here today.

I thank Deputy Daly. I appeal to members. I do not wish to restrict anyone but time is very tight.

I thank the Chairman and I promise I will not be too long. The two submissions are very powerful and they speak for themselves. The committee has learned a lot from them. It does not do much to allay many of the fears we have around how An Garda Síochána operates. When Dr. Singh was before the committee he was at pains to talk about some wonderful co-operation and work at operational level from gardaí.

He refrained from adding the same to dealing with the hierarchy.

Ms West has been with the organisation for ten years. She made the point that there has been a learning curve and that everyone has taken time to adjust to certain ways of doing things, and that applies to how the analysts operate as well. However, Ms Galligan made the following point in her submission. She said that despite the nine meetings ""It was now concluded that the methodology I had utilised in comparing the records of the Office of the State Pathologist and the PULSE system were “inherently weak”, “inappropriate”, “confined” and “restricted”. Given that Ms Galligan had nine meetings that included what were described as "robust discussions", surely they would have been aware of her methodology during those meetings. She has said that these aspects were not raised at any of the nine meetings. Were they aware of the methodology used that they ended up describing as inherently weak, inappropriate, confined and restricted?

Ms Laura Galligan

Yes. At the beginning of the 87-page report that I wrote in November 2016, the opening introduction is on the methodology and the method used. At the first meeting at which we met PDIM, I described in detail both my methodology and how I went about it as regards the Office of the State Pathologist and then back to PULSE. They were completely aware yet they never raised any concerns about the weakness or flaws in my methodology until we seen sight of the report on 8 May.

That is not just a learning curve. This is disingenuous, is it not?

Ms Lois West

We have said from the very beginning that we are not investigators. We were looking for others to come on board with us to get that consensus view as to whether there were issues. I have a difficulty in that whenever there is a homicide in this country now, we always get a phone call. Myself and my colleague will get a phone call asking for analytical support for the investigation. We have become nearly indispensable to supporting those investigations. From that point of view, it is clearly recognised that analysts add value to investigations. It is irrelevant that one is not actually an investigator because everybody has a different expertise and value to bring to an investigation. My concern with this was as follows. We recognised early on that we did not have access to the investigation files, and we never claimed to have had that access. We were concerned, when we saw report on 8 May, that it, perhaps, was not representative of the fact that we had always said, "Look, we have this and this but we do not have the investigations files." The report was also misleading in that it kind of focused on those being the two solo sources of information that Ms Galligan had when she compiled her report. In effect, she had access to other information such as coroners' findings and so on either because they were recorded on PULSE or she did a lot of open-source research around these to try to ascertain information that she could not glean from the PULSE system.

I am concerned that 15 months have elapsed since Ms Galligan produced the first report in November 2016 and we still have not seen the investigation files, nor have the members of PDIM seen all of the files. There may have some requested to clarify particular information. As of this point, there has not been an independent review of those investigation files. For my part, I cannot understand how PDIM could produce a report, and how certain assurances could be given on the basis of that, when those investigation files had not been reviewed by us or anyone else, as far as I could tell.

Ms Laura Galligan

I wish to add to that point. In the original report on the particular cases, I would have raised questions regarding the circumstances of the death and the cause of death. I was posing questions to the investigation and these were subsequently sent out to the investigation team as part of the review. The April report that we saw on 8 May did not address any of my concerns that were in my original report in November, so they were overlooked.

A member of the public would have to go through this with a fine-tooth comb in order to discover what actually transpired. Do the witnesses not think that this amounts to nothing short of a cover-up by senior management?

Ms Lois West

I would not want to go that far. I certainly would have concerns. We have four box files of records on the homicide review, so the Deputy will appreciate that it is quite difficult to synopsise that down, as best we can, into statements that can assist the committee. This matter has been ongoing for 15 months. There is a huge volume of records in the form of reports, emails and contemporaneous notes on this one issue. We feel that, in addition to our other responsibilities, we have done two full-time jobs for the past 15 months in terms of trying to get these issues raised and addressed.

Earlier, Ms West stated:

... on 12 May, 2017, as a direct consequence of the letter I had sent internally the day before, I received a telephone call ... I am unable to say who made this call. During this call, I was made aware that a report, which I had submitted on 11 April 2017 for onward transmission to the Policing Authority ... had never been sent to it. I was informed that this report had been discussed amongst senior Garda personnel prior to a private Policing Authority meeting on 13 April 2017.

Given that Ms West has worked in the place for ten years, and in light of her level of authority and expertise, how in God's name can that situation be explained? Can anyone be held to account?

Ms Lois West

I hope someone will be.

Has a process commenced whereby somebody will be made accountable for the situation?

Ms Lois West

Not that I am aware of. I would share such concerns. It does not feel right. I think we can all see that something is not right about the situation. It is our frustration about the way we have been treated and the 15 months of torment we endured while trying to raise these issues and have them addressed that brings us here today.

I do not know how the witnesses have remained sane. Since 2012, this committee has dealt with many different policing issues. We, as committee members, have found it mind-boggling that nobody has been held to account for what they did. People just say, "We will learn from that and now we will move on." It is incredibly worrying that there is no accountability. Let us say that the witnesses had the authority to hold people to account for some of the poor decision-making that has taken place at a higher level. In terms of dealing with all of the issues that they have raised, how can we hold people to account for their actions?

Ms Lois West

That is very much above my pay grade. Yes, I think this matter warrants investigation and needs an external eye to examine what has happened in the past 15 months. We may have our own views on the matter, and we have our own records. We certainly know how we have personally felt for the past 15 months. I guess the reason that we are here is because for the past 15 months it has felt like we have been holding senior Garda management to account but that is not our job. I am not exactly sure whose job it is. We are here today because we hope that something will happen.

As I stated, there will always be expertise within lower ranks and grades, on the Garda as well as the civilian side of the organisation. There are trained barristers and members with various experience within the Garda ranks. However, there is a tension between expertise and rank structure. It is very much a rank-driven organisation, and when an instruction is given by someone in authority , it is followed. The difference in this scenario is that we did not follow such instruction but, rather, stood firm because we so strongly believed in what we were fighting for. By virtue of the value systems with which we were raised, we know how to behave ethically, which is what we have done throughout this process. People may question the process we have followed, how we have come to be before the committee or the things we have said today, but that has all been done with truth, conviction and a determination to do right in terms of public service and ensure the right things are done. However, we need help to do that.

Ms Laura Galligan

Ms West and I want every death to be classified, recorded and investigated correctly. This is not a statistical issue for victims and their families. We never said it was. We understand the importance of working with the Central Statistics Office, CSO, but victims and their families are at the heart of this and that is what has driven us to do this through the pressure we experienced for a 15 month period.

What engagement have the witnesses had with Chief Superintendent Matt Nyland?

Ms Lois West

He was involved with policy development, implementation and monitoring, PDIM, at that time. He was the chief of that section so we engaged with him quite a bit.

Did the witnesses have engagement with Deputy Commissioner John Twomey and, if so, of what nature?

Ms Lois West

We had quite a lot of correspondence back and forth and also meetings in person with him.

Was their engagement with those individuals satisfactory?

That question may put the witnesses in an unfair position.

They are not obliged to answer.

As Chair, I wish to indicate that the witnesses are not obliged to respond in the blunt manner in which the question was put.

I thought I was being polite and discreet.

As the Deputy always is.

Ms Lois West

I will decline to answer the Deputy's question.

Did the witnesses feel they had the 100% support of Dr. Singh?

That question may also put the witnesses in an invidious position. I will leave to them the decision on whether to answer but I offer-----

The Chair is interfering with the witnesses. Perhaps he might leave them alone.

I am offering them the advice that if the question is too blunt, they may decline to answer.

Ms Lois West

It would probably be advisable to decline to answer that question.

I thank the witnesses for their contributions. They are two powerful women. Fair play to them.

All members are in agreement in that regard. I must appeal to everybody to be cognisant of time pressures and I know Senator Black will be a good example for Deputy Kelly in that regard.

I will do my best. I thank the witnesses for the phenomenal and amazing work they have done. They are a breath of fresh air in terms of their ethics, values and integrity knowing no bounds. It is great to know that there are people doing such great work, in particular in the environment in which the witnesses work.

I have many questions but I will heed the advice of the Chair to keep my contribution short. Deputy Clare Daly spoke about victims of domestic violence, which struck a chord with me. Did the witnesses mention that information in regard to domestic violence and hate related crimes has been misclassified?

Ms Lois West

Such incidents may not have been incorrectly classified but may not have been noted as a hate crime or domestic incident.

This issue may have been addressed by the witnesses but I wish to be clear on it. Is there is a possibility that some people are in danger because of such misclassification?

Ms Lois West

It is possible. It would be completely unrealistic to say An Garda Síochána could prevent every incident from happening, even if it were in possession of a perfect dataset. However, as people who deal with data, we know the importance of good data in terms of being able to reach good and satisfactory conclusions. It is critical that the data are sufficiently robust and accurate for us to have a chance to track an escalation of incidence. As Ms Galligan stated, Operation Devise was set up within the national protective services bureau, which is very enthusiastic to be referred cases where concern is raised. My concern is that that is currently being done in an ad hoc and piecemeal way and there are limiting factors to what we can do because of PULSE.

Victims and their families are always first and foremost in my mind. Two deaths were not be considered in the review for reasons that cannot be publicly disclosed due to the legislative framework. Briefly, to what legislative framework does that refer?

Ms Laura Galligan

It would be very difficult to explain without identifying the particular legislation, so I would prefer not to address that issue.

Ms Lois West

It concerns where certain things are laid down in law as to how things should or should not be done. We were striving for consistency in the approach to recording certain groups of incidents and also to ensure that at least some recording of certain incidents to reflect activity that would have taken place even though a direct investigation might not be conducted by An Garda Síochána. It is difficult to explain without going into it any further but there are certain legislative bounds that determine how certain incidents are dealt with.

I cannot imagine what it was like for the witnesses, in particular in terms of what they went through in January to September 2016 and especially around May of that year. Did they feel very isolated at that time? Was it just the two witnesses involved or was there a team of people? What supports did they have within their organisation, if any?

Ms Lois West

Had we not had each other, it would have been incredibly difficult. We have had much personal support from family, while other individuals have put the arm around us from time to time, reassured us and told us to keep going and that we were doing the right thing. However, it has been an incredibly lonely and isolated place. It is a breath of fresh air for me to be here today and to be able to address these concerns.

It is important that the committee wishes to support the witnesses as best it can. I thank them for their appearance today.

I call Deputy Kelly.

Brevity is not my strong point.

Is the Deputy going to rob the Chair of his moment?

We can stretch it for a few minutes.

I ask that he do his best to be brief.

I will do my best. I will cut half of my questions and will not overlap. I thank the witnesses for their attendance. They are the two best witnesses I have seen at a committee in my time flitting in and out of here over the past decade. I have seen all of their evidence, having watched the beginning in my office and been in attendance for the second half. I am a member of the Committee of Public Accounts and so cannot also be a member of this committee but I am a regular guest, and I thank the Chair in that regard. The courage shown by the witnesses in the face of great difficulty is exemplary, while the knowledge, clarity and professionalism they have brought to giving their evidence is the best I have seen. In terms of their knowledge of the subject matter, they have recorded and documented everything to a very high level and gone through everything in an incredibly impressive manner.

I will ask these questions quickly. In a response to a question from Deputy Wallace earlier, I felt like giving Ms West a round of applause when she spoke about the tension between expertise and rank structure. That summed up the situation we have all seen in An Garda Síochána for some time. With great clarity, Ms West spoke about ethics, truth and conviction and that she had to stand by what she was doing for the past 15 months. Has the culture changed in any way in recent months? When Ms West was asked earlier, she was correct not to discuss individuals because this is not personal, but she obviously feels let down. That is my first question about the culture. Has anything changed in recent months?

Ms West spoke earlier about the pressures and other matters. I was very much taken by the way Ms West stated how she personally had a duty of care to Ms Galligan. The second part of my question in relation to culture is as follows. Did Ms West's superiors from a reporting point of view maintain their duty of care to her professionally in her workplace?

Ms Lois West

I will take the second question first. No.

Does Ms West need another way of answering Deputy Wallace's question?

Ms Lois West

In terms of culture change, there are always times where fundamental things happen that force through change. I would certainly hope that this would be one of those, that there would be a recognition that there are people within An Garda Síochána, whether sworn members, civilian or whatever, who have valuable things to say, that is, expertise that is exceptional, and we should be making full and proper use of that.

The Deputy asked whether the culture has changed in recent months. If it has, it has not changed enough. I would certainly hope that there are some people who are taking some serious learning from what has gone on.

Ms West spoke earlier about how something changed in mid-September. What happened? Was it that certain individuals knew that this would probably explode, reputational damage could not be subdued anymore and they had to adopt a different tactic, or was there something else?

Ms Lois West

We always tended to find that there was that flurry of activity when key events were upcoming. I am not sure whether it was to do with another Policing Authority public meeting coming up on 28 September and whether there were reporting requirements to be met in advance of that.

Ms Laura Galligan

Maybe they knew how strong we were in our views. We could not ethically and professionally accept that there was nothing wrong with these 41 cases.

They reached a point whereby continuing with their strategy just would not work.

Ms Lois West

They probably slightly underestimated the power of the opposition.

Ms West is correct there. We have gone through everything relating to how dissatisfied Ms West was with the way in which she was dealt with. Ms West was shocked by what happened on 27 April and at subsequent meetings, etc. If people from the Policing Authority were watching Ms West and me talking now and they asked to meet her, would Ms West accept that request and welcome it?

Ms Lois West

Absolutely, yes.

Should they still meet both Ms West and Ms Galligan?

Ms Lois West

We would be happy to meet at any stage. As we have stated all along, this is not personal. By any stretch, this is not about trying to hang people out to dry. This is about trying to get done what we have wanted done from day one, which is to have the issues recognised and fully and properly investigated so that we can give genuine confident reassurance, both to the committee and to the public, that everything is as it should be.

When does the witness believe the Department of Justice and Equality was aware of her concerns?

Ms Laura Galligan

We would not have a time.

Okay, that is fine. The methodology is the same methodology that is being used now. I had the privilege of working on databases for years in a previous life and I know what a single point of failure is. In fairness, everything is wrapped around Ms Galligan's knowledge. Is Ms Galligan confident she has the resources going forward? Being honest with her, in my opinion, they do not have the resources to be able to conclude the work. She cannot give a date. I understand that. There are many different arrows out of this work that go into many different pies. Has Ms Galligan the resources? Would she welcome more resources?

Ms Laura Galligan

I will say that since the new review group has been set up, we have been offered the resources and offered another analyst. The resources I need is to get the time to go to the State Pathologist's office to review the files physically and then to go back and collaborate them with PULSE.

As resources would help, I thanked the staff in the State Pathologist's office and I will thank them again. They offer a huge resource and assistance to me in completing this report. A formal communication needs to be established between both agencies, An Garda Síochána, the Office of the State Pathologist, and the coroners so that there is a kind of communication between us all in sharing data, especially in regard to the recording of deaths to ensure that we are getting it right.

The data inaccuracy has an impact on statistics on homicides and homicide investigations which needs to go down to a level of detail dating back over a decade which will take a considerable amount of time. The most important aspect is getting the truth for the families of victims. In addition, what has come across clearly to me is that, because of the consequences of the 15 month delay and the fact that this has not been done properly, we have a situation where gardaí are not provided with the level of information that would link up ongoing investigations and that causes investigative risk every day. Would it be fair to say that is a serious concern? Second, the vetting office for An Garda Síochána is based in my county. This has a domino effect when it comes to vetting people because the information is not cross-checked and co-related. Third, when it comes to compiling data which has influence on policy which is directed in these Houses, that cannot be accurate either. Is it true that the original data inaccuracy, the investigative process in relation to homicide and those three items which I have outlined all involve serious risks?

Ms Lois West

It is. We do not want to scaremonger either.

Ms Lois West

There is a lot of good analytical work that we have done and that we can do. It involves quite a lot of cleansing of the data. There clearly are parts missing and we cannot quantify that. All we can do is try to work forward to put right what is wrong and to try to ensure-----

Effectively, these create risks.

Ms Lois West

They create risks, yes.

There were a number of changes in management. Ms West might outline, obviously not publicly here, where there were changes over the past couple of years, particularly in those 15 months. Somebody could co-relate decision-making with changes and see whether there is anything tangible that we can take from that. I thank Ms West and Ms Galligan.

I concur with the words of several members of the committee, not only in relation to Ms West and Ms Galligan's written submissions as read into the record here this morning but in their responses to questioning. Their testimony has been powerful. The most important aspect of all is that it is from the highest motivation of public service, and we acknowledge that. Certainly, Deputy Clare Daly and Senator Black will concur with me that, on the eve on International Women's Day, Ms West and Ms Galligan are a powerful duo and a credit to their gender and an example to us all, men and women alike, in public service.

I am delighted that we had the opportunity to host the delegates today. The picture I see is one where denial and obstruction have come into play. We see a culture that does not want to expose the fault lines at any cost and attention to this or that must be suppressed. When we had the senior gardaí with us, three weeks back I think, we were assured all 41 cases - I note the figure of 43, but 41 had specifically been pointed to between 2013 and 2015 - had been investigated. Those who presented were at pains to emphasise that point. It is a reasonable question to ask whether these cases, or even some of them - even one would be one too many - were appropriately investigated. It is the key question. We do not doubt that they have been investigated. However, the word "appropriate" is very important. We have all noted different reports where a suspicious death, or whatever else, has been reported on the news. RTÉ and other broadcast and print media will then report that the investigation has been upgraded to a murder investigation. The word "upgraded" has always stuck in my memory and it is the language used. I have always taken and believe I am right in saying the word "upgrading" not only as underscoring the tragedy of what has happened but also as reflective of the upgrading of the process of investigation to meet the needs of the particular case. Does Ms West concur that that is the key focus?

Ms Lois West

Absolutely. It is one of the fundamental issues on which Ms Galligan and I have been arguing. Our view is that if a scene is attended to and there is any possibility a person has met with foul play or there are suspicious circumstances, it should, first and foremost, be entered on the PULSE system as a homicide. I am not sure if there are particular difficulties of which I am not aware that would lead to this not happening. However, it seems logical to me that the investigation start high and work back. That would also give confidence to families and the public that absolutely everything was being done within An Garda Síochána to investigate such cases. I agree that there is an absolute difference between an investigation and a full, proper and complete investigation. I know that the media have picked up on this and want to clarify the position because we do not want scaremongering and the causing of unnecessary concern. What we always asked for was a full and independent review in order that we would be able to give confirmed assurance that everything was as it should be. There is no doubt that in the course of our work we did raise questions. Some have been answered and I am sure some will be as the review process moves into the next phase. However, I want to get away from the idea of crimes not being fully investigated. We want to get to a position where we can give assurance that we are satisfied everything is exactly as it should be.

I refer to the newly established working group, towards which the delegates have indicated some positiveness and good hope that things will transpire as they wish them to be. When they make reference to a full and independent review, is it an external examination in tandem or are they happy that the current signalled work programme, under the newly established and newly led internal body, is sufficient? Will they clarify the matter because, as a committee, we will be discussing all of these issues at the conclusion of our engagements? We will have representatives of the Policing Authority before us next week. We will also have representatives of An Garda Síochána back and these matters will be discussed with them. Will the delegates give us a sense of what they would like to see happen now?

Ms Lois West

Originally we probably envisaged something external to An Garda Síochána happening to ensure robustness and an ability to stand over it. There is nothing about the new review team, as things are running, that gives me a lack of confidence. It gives me greater confidence that Ms Galligan and I will be fully and completely involved in the process. As we have done up to this point, if we continue to have questions or are not satisfied, we will say so. We are working hand in glove with the new review team to identify the cases we believe need to be subject to a full and independent review. As I sit here, I have every confidence that that is what will happen, probably with the impetus of what has gone before in the past 15 months. Perhaps some lessons have been learned.

Ms Laura Galligan

It is also important and pertinent, as we are working on the review group, that the wider policy group look at the policy, governance and education issues in all areas of the classification and investigation of deaths. That should be looked at immediately. There is no point in reviewing from 2017 backwards and then in a couple of years having to do the whole thing again because nothing has changed.

The delegates indicated that they were pleased to have had the opportunity to present before the committee. I want them to know that, if things do not unfold in the way they would wish, the door to the committee will always be open to them in the future. If matters do not progress in the way they should, we will be very happy as a committee to play our part. I hope that will be some assistance to the delegates as the process takes it time in the period ahead. We will be delighted to engage with them again.

I have a quick point to make. Unfortunately, I had to leave. However, I was horrified last night to read the opening statements and to hear them being articulated again this morning at the committee. I do not have questions, but I just want to commend Ms Galligan and Ms West. It is the type of steely approach to do the right thing, stand by one's convictions and do what one believes is right and what has transpired to be right that the country needs. I salute the delegates as public servants and thank them for the work they have done. I concur with the Chairman that we will, as Oireachtas Members and as members the Joint Committee on Justice and Equality, play our role in supporting them, if need be. I say "Well done" to the delegates for their contributions.

I thank the Senator. On behalf of the committee, I thank Ms West and Ms Galligan for joining and addressing us so comprehensively on these important issues. Before we adjourn, I take the opportunity to wish everybody a happy St. Patrick's Day.

The joint committee adjourned at 1 p.m. until 9 a.m. on Wednesday, 21 March 2018.