Investigation into welfare concerns raised before a death - West Midlands Police, October 2022

On 17 October 2022 at 4:40pm, West Midlands Police (WMP) control room received a call from the Metropolitan Police reporting a concern for safety. The caller stated Female A's sister-in-law had contacted the police to report Male A (who lived in the WMP force area) was having mental health problems and making concerning comments. Male A and Female A had two children aged two years old and three weeks old.

At 4:47pm, the WMP call handler contacted West Midland’s Ambulance Service (WMAS) to report Male A’s behaviour. WMAS agreed they would deal with the incident, and the WMP call handler explained that the police would assist with any safeguarding issues identified, if needed. The call handler graded the call as a contact resolution, and closed the incident log. 

At 6pm, WMAS contacted WMP requesting a safe and well check to be carried out with Female A and the children, following reports that Male A had stopped Female A from feeding the children. The WMP call handler told WMAS he would re-open the original log and send it to dispatch. The call handler did not do this and instead, created a record of contact (ROC), which he graded as a contact resolution, and he then closed the entry. 

On 18 October 2022 at 3:42am, a neighbour of Male A and Female A called WMP to report an assault, and a baby not breathing. WMP recorded the incident and graded the call as an immediate response. The Police and Ambulance attend the property, where the baby was pronounced dead. Male A was arrested for murder of the baby, s18 wounding on Female A, and common assault on the neighbour.

During our investigation, our investigators examined several pieces of material including the incident logs, call recordings, and relevant police policy and procedures.

During our investigation, there was an indication that two call handlers may have behaved in a manner that would justify the bringing of disciplinary proceedings. We obtained their accounts under misconduct caution.

Our investigation concluded in April 2023 but we waited for external proceedings to conclude before publishing our findings.

We concluded an officer had a case to answer for misconduct.

In October 2023, a misconduct meeting was held and the allegation that a call handler did not carry out a THRIVE assessment in relation to the ROC from WMAS for a safe and well check was upheld. 

The call handler commented he has since undergone further training and has been signed off to continue his role in the call centre. The chair found that the allegation was proven, and the call handler was sanctioned a written warning, which remains in place for 3 months.

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 did not identify organisational learning.