Man found dead after requesting police assistance - Devon and Cornwall Police, September 2017

At 1.51pm on 23 September 2017, a man living in East Devon called Devon and Cornwall Police via ‘999’, requesting police assistance because he believed someone was breaking into his room. He said he could hear whispering and was worried someone was going to kill him. The call handler recorded that the man was suffering with paranoia and advised him to call the Ambulance Service. The call handler discontinued the call after five minutes; he started to create a log of the call and recorded that police would not be attending.

At 1.57pm, the man called ‘999’ again and spoke with a second call handler. He stated he was unsure if it was paranoia, but he believed someone was breaking into his home. The call handler discontinued the call after nine minutes. This call handler updated the log and requested that a supervisor assess the call, for police attendance to be considered.

At 2.07pm, the man called ‘999’ and spoke with a third call handler. During this call, he became agitated. Crashing and banging could be heard in the background and the call handler believed he was breaking things in his room. The man said that he had not taken medication for his paranoid schizophrenia. He also said he had taken cocaine and was feeling unwell. The call handler remained on the phone with the man for 49 minutes and upgraded the call to ‘prompt’, which required police attendance within 60 minutes.

At 2.22pm, Devon and Cornwall Police called the Ambulance Service and asked them to go to the man’s home, as they suspected he was experiencing a mental health crisis. The Ambulance Service advised that the man was third in the queue for ambulance attendance. At 4.40pm, the police called the Ambulance Service again.

The information recorded on the police log indicating that the man had not taken his medication, had taken cocaine, and was feeling unwell was not passed to the Ambulance Service. By this time, the man was 20th in the queue for ambulance to attend.

At 6.18pm, the Ambulance Service informed the police that, after gaining access to the man’s home, he had been found dead.

The post-mortem indicated that the man had died from toxic levels of cocaine. It was not possible to determine whether earlier medical intervention could have led to a different outcome.

During our investigation, our investigators obtained call logs of the calls made by the man to the police, and by the police to the Ambulance Service.

We interviewed and obtained statements from officers and staff within the force contact centre. We reviewed prioritisation of calls within the relevant policing area on the day. During our investigation we found indications that one call handler, three radio dispatch officers (RDOs) and a police sergeant may have behaved in a manner which would justify the bringing of disciplinary proceedings.

Based on the evidence available, as the end of the investigation, we were of the opinion that one call handler had a case to answer for misconduct for not taking appropriate action to safeguard the man, despite identifying him as vulnerable, and for being abrupt and dismissive with the man during the call. We were also of the view that one RDO had a case to answer for misconduct for not taking action to deploy police officers to the man’s address despite being required to do so by Devon and Cornwall Police policy, and for not taking appropriate action to safeguard the man despite identifying him as vulnerable.

We found there was no case to answer for the other two RDOs or the police sergeant.

After reviewing our report and decision document, Devon and Cornwall Police agreed that the call handler had a case to answer for misconduct. As the call handler had left the force, no further action was taken. The force also agreed that the RDO had a case to answer for misconduct and proposed to deal with this by management action to ensure the RDO reflects, learns and is given the skills and training to perform their role, especially in relation to management of safeguarding risks.

Our investigation highlighted a need for Devon and Cornwall Police to achieve greater clarity in their approach to concern for welfare cases. The force agreed that our investigation had revealed some wider issues and departmental failings. Devon and Cornwall Police has now addressed these so as to prevent a repeat of this incident.

We completed our investigation in October 2018 but waited until the inquest into the man’s death had taken place, in autumn 2019, before publishing its outcomes. The inquest recorded the cause of death as the toxic effects of cocaine in a patient with paranoid schizophrenia.