Concerns for woman’s welfare and police contact prior to her death – Lancashire Police, January 2023

On 10 January 2023, a Lancashire Constabulary police officer attended the home address of a woman, in response to a welfare concern that had been reported to North West Ambulance Service (NWAS). The officer was part of a multi-agency team, which included a paramedic and two mental health practitioners. 

On 27 January 2023, the woman was reported missing and subsequently found dead on 19 February 2023 during the missing-person investigation. 

We started an independent investigation, focusing on the contact the force had with the woman on 10 January 2023, following a referral from Lancashire Constabulary. 

Our investigation focused on the actions and decisions of the police officer who attended the woman’s address on 10 January 2023 and whether these were in accordance with policy, guidance and training. We interviewed the officer who engaged fully with our investigation and provided a full account of their decisions and actions. 

Our investigation concluded in April 2023. 

We waited for all external proceedings to be finalised before publishing our findings. 

We concluded there was no indication any police officer had behaved in a manner that would justify the bringing of disciplinary proceedings or had committed a criminal offence. However, we identified two areas of individual learning for the officer, which relate to recording information on police systems and activation of body worn video. We shared our findings with Lancashire Constabulary, who agreed with our findings. 

In our opinion, the most appropriate outcome to action the identified learning is through 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, in particular: 

• 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 woman’s death was held in late June 2023. 

The Coroner concluded her death as accidental; a result of falling into cold water and drowning. 

We carefully considered whether there were any organisational 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 organisational learning for Lancashire Constabulary in respect of updating its guidance documents for multi-agency vehicles, to ensure all police officers working in this role understand what is expected of them, as well as the provision of guidance for officers more widely when dealing with similar situations. 

Lancashire Constabulary confirmed they have reviewed and updated the guidance, following our findings. 

We therefore did not deem it necessary to use our legislative powers to issue recommendations under the Police Reform Act 2002 as we were satisfied with their response. 

Lancashire Constabulary committed to sharing such learning through their organisation learning board for implementation.