Investigation into the response to a concern for welfare call prior to a man’s death - Greater Manchester Police, December 2020
On 4 December 2020, Greater Manchester Police responded to an incident where a man had been reported as threatening to jump from a window. Officers visited, however, upon arrival, the man was sat on his bed. The officers spoke with the man, who told them he wanted help with his mental health and wanted to go to hospital. An ambulance had already been called but officers said they would take the man to hospital.
Officers ultimately made the decision not to take the man to hospital after feeling it was not safe to transport the man in a police vehicle owing to the man being unsteady on his feet, having an injury to his leg, and had consumed alcohol. Officers felt the man was not an immediate risk to himself and could await an ambulance in his room instead. Officers then left.
Evidence has shown that while officers were leaving the premises, the man fell from his window. He later died from his injuries.
We received a complaint from the man’s family that the officers failed to safeguard him before his death. We also received a complaint that a police sergeant was rude and unsympathetic to staff at the building where the man died.
During the investigation, we spoke to a number of witnesses, both police witnesses and members of the public, and reviewed radio transmissions and body-worn video footage connected to the incident. We also reviewed local and national policies and training to see how these were implemented by officers when they dealt with this incident.
We finalised our investigation in July 2021. We waited for all associated proceedings to be finalised before publishing our findings.
We determined there was no indication that a person serving with the police committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings.
We did not uphold the complaints but considered it appropriate that the officers reflect on the incident and recommended they went through the reflective practice review process (RPRP).
An officer reflecting on their actions is a formal process reflected in legislation. The reflective practice review process consists of a fact-finding stage and a discussion stage, followed by the production of a reflective review development report. The discussion must include:
- a discussion of the practice requiring improvement and related circumstances that have been identified, and
- the identification of key lessons to be learnt by the participating officer, line management or police force concerned, to address the matter and prevent a reoccurrence of the matter.
An inquest into the man’s death took place in November 2022 and reached an open verdict.
We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.
We made the following recommendation under paragraph 28A of Schedule 3 of the Police Reform Act 2002.
IOPC reference
Recommendations
The IOPC recommends that Greater Manchester Police should issue a reminder to officers regarding the breadth of assistance available from the Mental Health Tactical Advice Service (MHTAS).
This follows an IOPC investigation where two officers, who were involved in this incident, indicated that while they were aware that they could use the MHTAS service in order to seek advice in respect of Mental Health incidents, they were not fully aware of how the MHTAS service could assist them with respect to the incident they were responding to. The officers ultimately did not consult the MHTAS service in this case.
If officers had decided to consult the service, they may or may not have gained further information in relation to the incident they were dealing with, however, they almost certainly would have been able to benefit from advice on how to deal with the situation from suitably trained individuals. This advice could have influenced their decision making and assessment of risk.
The IOPC does, however, recognise that GMP has already embarked on project work to improve and strengthen the forces position with respect to their policing response to mental health incidents, which includes plans to increase awareness of mental health incidents through the work of the Mental Health Co-ordination Unit. The IOPC has also been told that officers have recently been provided with a 'MHTAS on a page' document (information as of 1 June 2021).
Do you accept the recommendation?
Yes
Accepted action:
GMP accepts the learning recommendation following this IOPC investigation.
In response to the learning recommendation I can advise that police officers across Greater Manchester have had the Mental Health Tactical Advice Service (MHTAS) on a page repeatedly and this has been delivered on shift briefings via the Electronic Briefing System (EBS).
Posters promoting the use of MHTAS have also been displayed in every police station in prominent locations as well as inside the Force Contact Centre (FCC) formerly the OCB.
HTAS has also been promoted on the forces intranet page and has featured on the forces Organisational Learning Hub e-mail that is sent out across the force and featured information relating to Mr Forster's death and the learning from it.
This work was undertaken in March 2021 in order to improve decision making and in order to abide by the mental health codes of practice which states that the least restrictive option should be considered when supporting persons with mental health. MHTAS assists staff to do this and as the legislation requires they should be consulted before any decision to detain anybody under section 136 of the Mental Health Act.
As well as MHTAS, officers have other support available to assist in their decision making including the 24/7 mental health helplines and the Mental Health Liaison Teams which are in each accident and emergency department.
MHTAS have been asked to produce monthly figures on its services use which will be supplied to DCI Curran, GMP's strategic lead for mental health, so that its service and use can be evaluated.
In addition to the above there are a number of initiatives planned for 2022. All Section 136 detentions will be managed via the Force Critical Incident Managers from 31 March 2022 who will ensure that the Section 136 is discussed with MHTAS prior to using the power. If MHTAS are not available then the officers also have the options now of speaking with one of the two Mental Health helplines for the Trusts. Posters and information have gone out during 2021 to all Districts regarding the helplines for Pennine Care and Greater Manchester Mental Health Foundation Trust and continue to be promoted.The Wigan District of GMP already have a mental health response car but on 31 January 2022, three further mental health response cars are due to be launched on the Bolton, Tameside and Oldham Districts. They are a police vehicle driven by a response officer who will work in company with a mental health nurse between 3-12pm seven days a week. They will respond to the mental health incidents reported to GMP for those areas. If they have any down time, they will pick up North West Ambulance Service (NWAS) mental health incidents. It is an opportunity to upskill the officers, increase the options to support the person in crisis, less likely to use Section 136 and direct referrals to General Practitioners (GP's). These are on a two month pilot until the end of March 2022 and will be subject to College of Policing model of evaluation as well as the Trust evaluation.Since the beginning of December 2021, there has been a daily huddle between GMP, NWAS and the two helplines for the Mental Health Trusts and they will redirect calls for support if they do not require an emergency services response. This is still in the pilot phase and evaluation is ongoing but it is based on a newly agreed RAG (red, amber, green) for Greater Manchester (GM) that means that in the future lower risk cases will be redirected to the mental health helplines and a new multi-agency service which is the subject of a new GM group with the working title of "RAG implementation group". They are reviewing whether MHTAS service could be completely remodelled to receive calls via a 111 type service.Assistant Chief Constable Sykes now line manages the Prevention Branch Chief Superintendent and the Force Contact Centre (FCC) Chief Superintendent who come together once a month with the Mayor's Office Mental Health and Public Service Reform leads to discuss the future model of service for Greater Manchester with a view to improving the response and moving away from a response reliant on emergency services.
A Detective Chief Inspector from the Professional Standards Branch.