The Independent Police Complaints Commission independent investigation into how Joanna Michael’s emergency calls prior to her murder were handled has concluded that she was failed by Gwent Police, South Wales Police and the 999 system itself.

On 5 August 2009, Joanna Michael was murdered in her own home in St Mellons by Cyron Williams, who was subsequently sentenced to life imprisonment with a minimum tariff of 20 years in prison.

Two call handlers employed by Gwent Police and South Wales Police respectively were found to have failed in the performance of their duties. The Gwent call handler faces a disciplinary panel on a charge of gross misconduct, while the South Wales Police call handler also faces disciplinary action.

IPCC Commissioner for Wales Tom Davies said: My thoughts are with Joanna’s family and friends today for the tragedy they have endured.

This was a terrible crime that was perpetrated by Williams. He brutally murdered a young mother in her own home where her two children were staying.

Joanna rang the police because she needed urgent assistance and was denied timely help because of a fatal combination of technological and human errors.

The investigation found that Joanna’s emergency phone calls from her mobile phone were misrouted by the mobile phone mast system to Gwent Police which did not help her situation.

Joanna was then failed by the two police forces at an organisational level with their policies, training and communication systems between the two forces. She was further failed by the actions of the two individual call handlers dealing with her request for help.”

2.29am Joanna dialled 999 and made her first emergency call to the police. The Gwent Police call handler graded the call as requiring an immediate response but took insufficient details.

2.31am On the basis of the poor information provided the SWP call handler graded the call as requiring a ‘priority’ response – which has a target response within 60 minutes, rather than an ‘immediate’ response – which is attendance as soon as possible.

2.43am Joanna made a further 999 call, which was again received by Gwent Police, and in which Joanna is screaming and told the control room operator that she was in St Mellons and then the phone line went dead.

2.45am Gwent Police told SWP about this latest call and the SWP control room operator then re-graded the incident at 2.46am as requiring an ‘immediate’ response. Two officers were immediately despatched to St Mellons.

2.46am a member of the public called 999 and was misrouted to Gwent Police as well and informed the operator that there was a domestic dispute at Joanna’s house and said they could also hear children screaming.

2.49am a member of the public called the police and was put through to the Gwent Police control room and told them that somebody had been stabbed at Joanna’s address. Gwent Police called for an ambulance and told SWP about this latest call and that an ambulance had been called.

2.51am SWP officers arrived some five minutes after the call was graded an immediate response to find that Joanna had been murdered.

Mr Davies added: The simple fact is that at 2.29am when Joanna called 999 an immediate police response could have got to her house in five minutes. Because of all the various failings the emergency response did not arrive until 2.50am, when she had already been stabbed, probably at about 2.45am.

The IPCC cannot say that an earlier response would have saved Joanna’s life. For all we know if the police had attended Joanna’s house at 2.35am Williams may have just waited until the officers had left before resuming his murderous intentions.

What we can say for certain is that more could and should have been done for Joanna, who was denied the opportunity for a prompt response which may have led to a different outcome.

The service that Joanna received in the early hours of 5 August was below standard and has led to both police forces deciding on disciplinary action for the two call handlers.

There is a vital public interest in sharing the outcomes of our investigation and I have decided in this case to publish a Commissioner’s Report, which includes details of the investigation and the recommendations made. I am grateful that both police forces have accepted these recommendations in full.

It is important that the public continues to have confidence in the 999 service. We found that instances of mobile phone calls to 999 being misrouted are very rare. The two police forces have put in place a mechanism to help them overcome these rare technical glitches.

In the summer of 2009 there were five IPCC independent investigations into four murders and a missing person report where the woman was found dead. In part these cases shared common issues around call handling or dealing with domestic abuse and I have decided to issue a separate Commissioner’s Report in the next month or so which details the common findings and our recommendations.

However, at the core of the Joanna Michael case is the human tragedy that has beset her family. Nobody set out that evening last August to deliberately handle Joanna’s requests for help badly and, of course, the mobile phone system did not wilfully misdirect Joanna’s 999 phone calls to the wrong police force.

But no amount of learning from this tragic case will assuage the grief that Joanna’s family are enduring. Joanna, her children and her whole family have all been let down by the service Joanna received on 5 August 2009.”