Police contact with woman prior to her death – Essex Police, March 2022

In early March 2022, a woman contacted Essex Police multiple times. Her comments and manner raised concerns about the woman’s welfare. Essex Police requested an ambulance attend to assess her mental health, but East England Ambulance Service (EEAS) did not consider her to be in crisis and subsequently requested that the police attend. Police officers did not attend her address and the log was closed.

A couple of days after initial contact with the woman, officers were sent to her home address following another welfare concern, but they did not gain entry to the property. The woman informed the call taker that she had taken medication and an ambulance was called; the police shortly left afterwards.

Later the same day, EEAS attended the address. After gaining entry with the assistance of the fire service, they found the woman dead. 

During our investigation, we obtained and reviewed radio communications, body worn video footage and compared the evidence to local and national policies. We also obtained and reviewed witness statements.

During our investigation, we identified that three police officers and two members of police staff may have behaved in a manner that could justify the bringing of disciplinary proceedings. They co-operated with the investigation and provided accounts of their actions. 

Our investigation concluded in October 2022. We waited for all external proceedings to be finalised before publishing our findings.

We identified that the actions of two police officers fell below the expected standard and concluded that they had a case to answer for misconduct. We recommended that the most appropriate proceeding would be the reflective practice process. 

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.

Despite not having a case to answer for misconduct, we recommended the other police officer undergo the reflective practice process to aide individual learning.

After reviewing all evidence, we concluded that the two members of police staff under investigation did not have a case to answer for misconduct.

In August 2023, an inquest was held to help establish the woman’s cause of death. The Coroner recorded a verdict of misadventure.

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. 

In this case, we identified an area of organisational learning to ensure there is clear guidance on who is responsible to update agencies, including medical services, when there is a significant change in circumstances or police attendance to an incident.

We issued our recommendation to Essex Police under section 10 of the Police Reform Act 2002. This legislative power does not require the police service to outline their actions in a formal, public response.