Contact with man before his death – North Wales Police, November 2021
In October 2021, a man was reported to be climbing on the roofs of houses and to be potentially under the influence of drugs. Police attended immediately, but the man had fled the scene before they arrived. A search was carried out for the man, without success, and it was assumed that the man had taken shelter with associates, as he had a long history of evading the police.
The incident log was closed the next day. The day after, the man’s sister reported him missing, as neither his family nor his friends had been able to contact him since the incident. Area searches were carried out over the next few days until a local farmer discovered the man’s body in a fast-flowing river near his property.
We obtained and reviewed CCTV footage, incident logs and statements from officers. We also reviewed statements from the family members and interviewed three officers under misconduct caution.
We finished our investigation in October 2022.
We determined that no officer subject of this investigation had a case to answer for misconduct or for gross misconduct, but that there was practice requiring improvement, which should be dealt with 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 was held in April 2023 and concluded a drug-related death, with a medical cause of drowning.
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 identified areas for organisational learning and issued recommendations.
IOPC reference
Recommendations
The IOPC recommends that North Wales Police should incorporate the dangers of confirmation bias, encourage critical questioning, challenging assumptions, and the importance of exercising professional curiosity in matters of concern for welfare and Missing Person investigations. The force should ensure that the issue is covered in training and consider an appropriate methodology of how officer bias and assumptions can be challenged.
This follows an IOPC investigation where neighbours reported a male in distress up on the roof of their terraced houses 'off his head on drugs' and asking for police to be called. He was unsuitably dressed for inclement weather and wearing one shoe. The male made off prior to police arrival and his whereabouts thereafter could not be established. There was evidence that officers assumed from the outset that the male was evading the police and had gone to ground having made off because he believed he would be arrested for criminal damage to the roofs and TV aerials. The male was well known to police and several officers had experience of his evading arrest in the past when wanted. He was later reported missing and was found dead in a local river some days later. Arguably, if officers had taken a more questioning approach, they could have considered that it was equally possible in the circumstances that no one had seen him in the intervening period because he had come to harm.
‘Confirmation bias is ‘the tendency to seek, attend to and interpret information in a way that is consistent with our preconceptions, including expectations and pre-existing theories’ (College of Policing, 'Conducting effective investigations' PDF, July 2022). College of Policing Authorised Professional Practice (APP) states that 'Officers and staff should exercise professional curiosity to actively identify and investigate vulnerability-related risks, so they can deliver the appropriate policing response. Professional curiosity includes: exploring and understanding what is happening by asking questions and maintaining an open mind' (College of Policing 'Curiosity' web page).
Recommendation accepted
This recommendation is accepted and action is being taken.
In understanding the conclusions of this investigation, the issues that can be caused by confirmation bias are recognised, and how there is always a need for professional curiosity. The force is developing HYDRA learning packages specifically around managing missing person occurrences for Officers and Supervisors in which these specific issues will be covered.
The IOPC recommends that North Wales Police take steps to understand supervisors’ experiences of carrying out risk grading for missing persons cases, to determine whether further training may be required to ensure that the investigative actions carried out are consistent with the grading provided.
This follows and IOPC investigation where a North Wales Police Missing Person's Coordinator reviewed a missing person investigation and concluded that despite being graded as medium risk throughout, supervisors were setting and carrying out actions that were consistent with a high-risk missing person investigation including requesting media releases, arranging drone searches, carrying out financial and mobile phone checks and utilizing the informal intervention of specialist search officers. Where officers are required to carry out actions consistent with high risk missing person investigation the questions inevitably arise why are the investigation is not graded as high risk.
Recommendation accepted
This recommendation is accepted, and action is being taken.
There is a HYDRA package under development for Supervisors in which the risk grading for missing person cases will be covered, to improve knowledge and critical thinking in this area.
The IOPC recommends that North Wales Police allocates a dedicated Single Point of Contact (SPOC) to families/next of kin during Missing Person Investigations where possible. The SPOC should ensure the family know who their SPOC is, provide regular, meaningful updates and explain the actions taken by police.’
This follows an IOPC investigation where the family of a missing person had contact with multiple officers over a period of days and were provided with ad-hoc updates both in person at the local police station and by telephone about the ongoing investigation.
Whilst updates given to the family by various officers and staff were no doubt well-meaning it led to a situation where the information given had a negative effect on the family's view of police actions as they were not given any context for the decisions. There is evidence of lack of sharing information between the family and the police e.g. the police were unaware the family were carrying out ground searches. A more consistent communication approach and the ability to provide context to police actions could potentially prevent relations between police and the family from declining and provide reassurance.
Recommendation accepted
This recommendation is accepted. Action will be undertaken.
The issues raised in these recommendations have oversight and will be progressed through the MFH (Missing from Home) Working Group. It is expected that this recommendation will be progressed through this forum.