Contact between a man and police before he is found dead - West Midlands Police, September 2018

On 15 September 2018 West Midlands Police received three 999 calls from a man who was having a mental health crisis. The man said he was hearing voices in his head and that he felt like he wanted to hit somebody.

When officers arrived at the man’s home, they could not get any reply despite knocking on the door and calling his mobile phone. They made the decision to leave. Officers returned to the man’s home some hours later. They forced entry into his flat, where they found him dead. The man appeared to have taken his own life.

Our investigators examined the 999 calls and body-worn video, obtained witness statements, and examined both national and local policies with regards to the actions and decisions of all of the officers who dealt with this matter.

Evidence indicated that, during all three of the 999 calls, the man stated clearly that he wanted to cause serious harm to someone, but at no point did he mention that he was going to self-harm. The evidence tended to support the officers’ decision not to force entry when they first arrived at the man’s flat as there appeared to be no indication the man was a threat to himself at that specific time. In our view the decision appears to have been justified and proportionate.

Evidence also showed that the caution of both police and ambulance services in attending was proportionate given that the man had previously been violent towards officers. This appears to be amplified by his expressed statement that he was upset to the point of wanting to attack someone.

While it appears to have taken a long time for officers to return to the man’s flat, in our opinion it was this length of time between sightings or contact with the man which made the difference and caused the second officers to believe it was justified and proportionate to force entry.

Based on the evidence available we found no indication that any person serving with the police may have behaved in a manner that would justify the bringing of disciplinary proceedings, or had committed a criminal offence.

After reviewing our report, the force agreed.

We completed our investigation in February 2019 but waited until the inquest into the man’s death had concluded to publish its outcomes. The inquest recorded an open verdict.