Investigation into how police dealt with a call for assistance for a man who was later found dead - Devon and Cornwall Police, February 2022

At 5.33pm on 8 February 2022, a woman contacted Devon and Cornwall Police to express concerns for the welfare of her partner, after receiving a message from him saying ‘it’s too late’. The Southwest Ambulance Trust were informed but no police resources were dispatched. The woman later returned home at 8.22pm, to find her partner dead, having apparently hung himself, almost three hours after she had called the police. 

We investigated the Devon and Cornwall Police response to the concern for welfare report made in respect of a man on 8 February 2022, specifically: 

• whether the concerns reported by the caller were appropriately risk assessed and graded
• whether the decision not to deploy police resources was appropriate in view of the circumstances reported 
• to establish whether the log was reviewed post-closure, and whether any such review was sufficient
• to consider whether police action was in accordance with applicable legislation and local and national guidance, policies, and procedures.

Our investigators reviewed police and Ambulance Service documentation and recordings of the phone calls made, along with obtaining witness statements from the man’s partner, police officers and staff involved and the Ambulance Service despatcher. The evidence indicated that, after speaking to the woman, the police call handler called the Ambulance Service and also sent the incident log to a despatcher. The despatcher then referred the incident to a sergeant in the police control room, to consider whether police should attend or whether the incident should be left to the Ambulance Service. 

Before the Sergeant was able to review the incident, the call handler who had taken the original call had closed the police incident log, which caused it to disappear from the sergeant’s computer screen. The sergeant stated that, if he had had chance to review the incident log before it was closed, he believed he would have asked the call handler to call the woman back to obtain more information, and he could not say, based on the limited information recorded by the call handler, whether police officers would have attended.

The call handler, who was new in their role, stated they had closed the incident log on the advice of another call handler who was acting as their mentor. The mentor accepted they would have agreed to the incident log being closed. All of the police officers and staff involved accepted that this incident had not been dealt with in accordance with the Devon and Cornwall Police Concern for Welfare Policy, which required incidents where there was any doubt to be reviewed by the control room Sergeant before being closed. The police call handler also stated that, based on a further eight months of experience in the role since the incident, she was now aware that she could have asked the woman to provide further detail, such as the man’s mental health history.

We finalised our investigation in November 2022.

We were of the opinion that the call handler did not record sufficient information on the incident log and they stated that, if they were dealing with the same incident again, they would record more detailed information regarding the mental health history of the man involved. The call handler has clearly reflected on their performance in dealing with this incident, which occurred when they were still relatively inexperienced in their role. 

The mentor accepted that the call handler would have asked them if the log could be closed, and that they would have agreed. The Mentor could not recall if they asked the call handler to confirm whether a response had been received from the control room sergeant. The mentor accepted that the closure of the log before the control room sergeant had provided a response was a breach of the relevant Devon and Cornwall Police policy. The mentor stated that, if he had become aware that the log had been closed without a response from the sergeant, they would have reopened it and asked them to respond. However, the mentor reiterated their view that the outcome would have been the same.

We decided that it would be appropriate to address the performance issues for both the call handler and the mentor, informally via the individual’s line management.

Following consultation with the force, they agreed with our findings and proposed action.

We concluded there was no indication that a person serving with the police committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings.

An inquest in December 2023 reached the conclusion of suicide and that the man had a long-term history of mental health issues. On the 8 February 2022, he took his own life by hanging himself from the banister at his home address.

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 made an organisational learning recommendation to Devon and Cornwall police, under Section 10 of the Police Reform Act 2002, to review and amend their Concern for Welfare Policy to provide clarity around 'immediate and identifiable risk' with the possibility to include provisional examples as evidence.