David Kelly was reported missing shortly before midnight on 17th July 2003.
At around 05.15 on 18th July 2003 a significant number of police officers met to consider the situation and how to proceed. See, for example, the transcript of the evidence of Assistant Chief Constable Michael Page on the morning of Wednesday 3rd September 2003 at pages 17 to 21.
It was obvious that Dr. Kelly's disappearance should not be treated as a routine missing person inquiry. And, from the beginning, Thames Valley Police had not done so, for example sending up a helicopter with heat seeking equipment within hours of the disappearance being reported.
However, lots of activity is no substitute for asking the right questions.
Of course, there was a possibility that Dr. Kelly might be found safe and well.
However, a competent and diligent police force had to consider less congenial possibilities, including the possible discovery of Dr. Kelly's body.
In the event that a body was found it was already obvious that an unusual set of circumstance surrounded Dr. Kelly's disappearance.
The possible causes of death should already have been in the minds of detectives at the 05.15 meeting.
And, crucially important, someone should have been considering how to collect evidence that would allow the correct cause of death to be established.
Even prior to Dr. Kelly's body being found the Police should have been considering how to investigate any of the following possibilities and how to distinguish between them:
1. Natural causes
Given the nature of the circumstances, particular attention ought to have been given to the possibility that murder could be dressed up as suicide.
In other words, from the beginning the collection of evidence and the interpretation of it should have considered the possibility of highly skilled third party involvement where murder was dressed up as suicide.
I can find no evidence given to Hutton that indicates that the possibility of murder dressed up as suicide featured significantly in the thinking of Thames Valley Police.
If such thinking was absent then, in my view, Thames Valley Police were grossly negligent.
If the question of murder dressed up as suicide wasn't seriously considered then the failures which follow become much easier to understand.