Man dies following contact with police - Cleveland Police, August 2017

At 10.24am on 15 August 2017, a man approached a Cleveland Police officer in a distressed state, asking to be arrested. The officer was concerned about the man and took him to a mental health hospital for a mental health assessment, as a voluntary attendee. They arrived at hospital at approximately 11.30am; the officer stayed with the man for 30 minutes and then left the hospital at approximately 12pm.

At 12.06pm a member of the hospital staff called Cleveland Police to advise the man had left the hospital before being assessed. Control room personnel passed this information to the officer at 12.11pm and the log was closed. No further investigation took place to locate the man

On 16 August 2017 at 7.03am, a member of the public found the man’s body. He was pronounced dead at 10.34am.

During the investigation, our investigators interviewed one police officer and three contractors working in the control room for alleged misconduct, and took witness statements from hospital staff. They also obtained audio recordings of calls regarding the man, and documentary evidence from hospital and police systems.

At the end of the investigation, based on the evidence available, we were of the view that the police officer had acted appropriately in their dealings with the man. The officer believed that they were simply being notified by the control room that the man had left hospital because of their earlier contact with them, and that any further action should have been directed by the control room. We considered this to be reasonable in the circumstances and were therefore of the opinion that the officer did not have a case to answer for misconduct or any performance issues to address.

We were also of the opinion that the performance of two contractors working in the control room could be considered unsatisfactory for the following reasons: failing to conduct a risk assessment; failing to consider the man as a missing person; and failing to ensure that appropriate safeguarding enquiries were carried out after the man had left hospital without being assessed. We found no performance issues for a third contractor working in the control room.

After reviewing our report, Cleveland Police agreed that the performance of both control room contractors would be dealt with as unsatisfactory performance, to include a meeting with their line managers. The force will also deal with the matter as organisational learning.