Death of man following police contact – Devon and Cornwall Police, July 2019

On 7 July 2019, a man called 999 to report that his neighbour had threatened to take his own life. He stated that his neighbour was under the influence of either alcohol or drugs and had been hospitalised after an overdose within the last three months. The neighbours had a close relationship as they had known one another for many years and had familial ties.

The call handler graded the log as a priority. Subsequent log entries indicated that no resources were available to attend within the one hour target timeframe.

Officers attended approximately four hours later. They informed the Control Room that they had found a man hanging, and that he was not conscious or breathing. An ambulance arrived an hour later and the man was pronounced dead.

We specifically investigated the risk assessment and grading of the 999 call, reason for any delay in resourcing this incident, the actions and decisions of the officers who attended the scene, whether the officers and staff involved in this incident acted in accordance with the relevant policies and procedures and two complaints raised by the man’s mother.

The complaints related to the time it took officers to attend the call and the actions of police when an ex-partner had reported an incident where the man displayed an intent to harm himself.

We obtained and reviewed the incident log, the 999 call recording, relevant police radio transmissions, other logs received at around the same time, and police body worn video footage. We also obtained accounts from officers and staff involved in the incident, and obtained and reviewed relevant local and national guidance, policies and procedures.

Our investigation concluded in March 2020. We waited for all external proceedings to be complete before publishing our findings.

Our investigation did not identify any indication that any person serving with the police may have committed a criminal offence or behaved in a manner that would justify the bringing of disciplinary proceedings.

One complaint was upheld. We believed that the resourcing issues were a matter of significant concern, and that it was appropriate to uphold this complaint, given the information reported and the grading ascribed to the call.

The other complaint was not upheld. We concluded that officers were able to attend promptly on this cited occasion. A vulnerability screening tool (ViST) was later submitted, in accordance with force policy. We were of the opinion, that there was nothing more the officers could reasonably have done, in these circumstances.

In December 2022, a Coroner reached an open conclusion. The record of inquest stated, “The evidence is not sufficient to conclude that it is more likely than not, that [the man] intended to take his own life. It is possible that a significant delay in responding to an emergency call, caused by a lack of resource deployment officers, and/or a lack of police officers on the ground contributed to the outcome.”

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, learning relating to concerns around staffing levels in control rooms and in the local policing area during the summer was identified, but by the force. We therefore did not progress these as quick-time recommendations as Devon and Cornwall Police had actioned their identified learning by the time our investigation concluded.