The Independent Police Complaints Commission has found that a station receptionist and a detective constable at Kennington Police Station could have done more to deal with threats against teenager Arsema Dawit who was killed in Baylis Road.
The IPCC has published the findings from its independent investigation into concerns raised by the family of Arsema Dawit into the police action in the months prior to her death.
On 30 April 2008 15-year-old Arsema Dawit, accompanied by her mother and cousin, went to Kennington Police Station to report an assault and threats to kill made by her ex-boyfriend Thomas Nugesse.
Arsema Dawit was killed on 2 June 2008 by Mr Nugesse at Matheson Lang Gardens in Baylis Road, Waterloo.
On 20 May 2009 a jury found Mr Nugesse guilty of murder and the judge ordered him to be detained indefinitely in a secure hospital.
The IPCC investigation examined the circumstances surrounding the police contact with Arseam Dawit between 30 April and 2 June 2008.
It found there were collective and organisational failings in the handling of Miss Dawit's allegations.
In particular, the investigation looked at the actions of an inspector, a detective inspector, a detective constable and a station receptionist. It found that a station receptionist failed to inform a senior officer that there was an allegation of a threat to kill, to record contact details for Arsema Dawit's cousin and to seize mobile phones as evidence.
The investigation also found that a detective constable, who investigated the complaint, did not conduct a timely and effective investigation. A culmination of leave, other work commitments and a reliance on a schools officer to make contact with Ms Dawit, meant progress by the Detective Constable was slow.
"This is an extremely tragic case," says IPCC commissioner Rachel Cerfontyne.
"Nothing can compensate for the loss of a loved daughter and I again extend my sincere condolences to Ms Dawit's family and friends.
"While our investigation has found that a station receptionist and a detective constable could have done more, neither were responsible for what happened to Miss Dawit.
"Tragically through omission, misunderstanding and assumption, the messages and information given by the family on the night of 30 April were not sufficiently acted upon.
"I was concerned by the high workload of the inspectors interviewed as part of our investigation, in particular the almost unmanageable volume of work some supervisors are responsible for and the risk it creates of cases falling through the net.
"However, I am encouraged by the fact that the MPS has conducted its own critical incident review of the case, which resulted in eight recommendations, including a review of available supervision resources. I believe these recommendations go a long way to ensure incidents like these do not happen again."
The station receptionist has received management action together with a development plan regarding work performance. The detective constable has been spoken to by a senior officer about the role as an investigator and has been given a number of learning points to take forward.
The inspector and detective inspector were found to have both acted appropriately during their involvement with the case.
"This murder was a tragic loss to this family and the Metropolitan Police Service offers its condolences to the Dawit family for the death of their daughter Arsema," says Commander Simon Bray.
"The MPS referred the case to the IPCC on the 4 June 2008, two days after her murder. We also conducted our own critical review and reported the findings to the IPCC in the August of 2008.
"The IPCC made eight recommendations to the MPS, seven of which we have addressed. The eighth recommendation is an on-going project which has formed part of the new development programme in Territorial policing to improve our overall operational effectiveness.
"As the IPCC report has found, neither of the staff investigated were responsible for what happened to Arsema Dawit, but there was organisational learning from the incidents prior to her death. We welcome the recommendations from the IPCC and have incorporated the learning into our development programme.
"We expect the highest level of professionalism from all of our staff and accept the failings in this case."