Police response to concern for welfare - Warwickshire Police, October 2018

A man was admitted under Section 2 of the Mental Health Act to a mental health care facility in the West Midlands and was given leave to return home with medication for the weekend commencing Friday 12 October 2018. He was required to return on the Monday but did not do so. At 3.51pm on 15 October, a member of staff from the facility called Warwickshire Police and reported that the patient had been experiencing psychotic symptoms, and that he had been given medication for his weekend release, without which his condition may deteriorate.

A Warwickshire Police constable was dispatched at 6.25pm on that day, arriving at the man’s home at 8.32pm, and with the help of his landlord found him in his room. The officer talked to the man, who subsequently agreed to return to the mental health facility. The man walked out of his room first, followed by the officer, and the landlord. While descending the stairs the man fell down, hit his head and lost consciousness, ending up at the bottom.

The officer ran down the stairs and placed the man in the recovery position. An ambulance was called and arrived at approximately 9.09pm. Paramedics commenced cardiopulmonary resuscitation and the officer was asked to assist with chest compressions, which he did in line with their guidance. The ambulance took the man to hospital, where he received treatment for life-threatening injuries. He was kept in the Critical Care Unit as he had suffered severe hypoxic brain injury and an out-of-hospital cardiac arrest, but died there several days later on 23 October 2018.

Our investigators attended the scene and post-incident procedure and the police constable involved provided an initial witness statement. We gained a more detailed account from him approximately a week later, along with statements from another officer who attended the scene and an independent witness to the events. We viewed and assessed body-worn video footage, radio transmissions, a recording of the call reporting the matter to the police, and relevant incident logs. We also considered medical records and mental health documentation for the man who died.

We were of the opinion the police constable treated the man with dignity and patience and had acted in support of his welfare. The man’s fall down the stairs was a tragic accident that was not reasonably foreseeable. There was no evidence that suggested the officer had coerced the man into walking when he was incapable or unwilling to. The evidence showed that the officer immediately called for medical help and additional police attendance and did everything that he could to medically assist the man after he had fallen.

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

We concluded our investigation in April 2019 but waited until the inquest into the man’s death had concluded in early 2020 before publishing the outcome.