Man found dead after being reported missing - Thames Valley Police, April 2018
On 17 April 2018 a man was taken into custody by Thames Valley Police for an alleged sexual assault. Following his release from police custody the next day the man was reported as missing after he sent his fiancée a suicidal text message. Thames Valley Police conducted a high-risk missing person search and found the man on 19 April. He had taken his own life.
During the investigation, investigators interviewed several witnesses, including family members and friends of the man, police witnesses and a custody trainer.
Evidence showed that the man had disclosed to the custody officer during his booking-in process that he had a mental health condition, a history of self-harm and suicide attempts. The man had previously served a custodial sentence for similar sexual offences and was a registered sex offender.
Based on the evidence available we were of the opinion that one police officer had failed to consider the risks to the man at the booking-in process, when the man informed him he had personality disorder and previously tried to self-harm (including the increased risk factor he had been detained for an alleged sexual offence), and had also failed to offer the man support for his mental health issues. As the officer accepted his failings, and we found no evidence of wilful misconduct, we considered that this could be appropriately dealt with by management action.
We were also of the opinion that the performance of another officer may not have been to the standard expected of an experienced police officer, and suggested that this officer also receive management action.
After reviewing our report, the force agreed and advised that both officers would receive management action.
We completed our investigation in February 2019 but waited until the inquest into the man’s death had completed before publishing its outcomes.
IOPC reference
Recommendations
Thames Valley Police’s (TVP) custody records contain a question asking detainees “If you are suffering from mental health problems, depression or considered mentally vulnerable we must put specific support in place. Do you need this support? If yes, give details”. During the course of the investigation it was identified that custody staff do not routinely ask whether detained persons who have disclosed mental health issues need support. The IOPC recommends TVP should remind custody staff of the requirement to explore the support a detained person might need if the person discloses that they have mental health issues, or they are considered to be mentally vulnerable. If custody staff become aware that a person has mental health issues or is mentally vulnerable, they should consider what support that person requires.
Do you accept the recommendation?
Yes
Accepted action:
TVP will remind custody staff of the requirement to explore the support a detained person might need if the person discloses they have mental health issues, or they are considered mentally vulnerable.
Force-wide reminders will include the fact that if custody staff become aware a person has mental health issues or is mentally vulnerable then staff will consider what support that person requires.
[On 14 Feb 2020 TVP followed up with the following actions they have taken as a result of the recommendation:
"Thames Valley Police (TVP) currently provide training to both new Custody Sergeants and new Detention Officers on initial custody courses. This training includes guidance from NHS Liaison & Diversion services (L&D) on the types of vulnerabilities and signs for staff to look out for that may indicate a mental health issue or a vulnerability with a detainee. Sgts are also trained on how to deal with those in mental health crisis with a clear process established for Mental Health Act assessments and the use of S136 in custody.
In the last quarter of 2019 TVP ran training days for existing Custody Sergeants who were delivered inputs on vulnerability, autism and again from L&D. The inputs included how to refer detainees into L&D and gave guidance on the type of case that should be referred. This training reached approximately half of TVP’s Custody Sergeants. TVP intends to run further training days for the remaining Sergeants to cover these areas (see below).
All existing Detention Officers have received training inputs on mental health, whether this be via the above training input on initial courses or from being employed by their previous company Noonan when the Detention Officer role was contracted out by TVP (Detention Officer’s transferred into TVP employment in April 2019).
Moving forward TVP has begun developing its training days for existing custody staff with a view to providing 2 training days each year for each member of custody staff for the delivery of key issues. This will include both Custody Sergeants and Detention Officers. The first of these will occur around June/July 2020. The second will be held later in 2020 and will be joint training delivered by TVP and its healthcare provider Mountain Healthcare. This will include training on mental health (including scenarios) amongst other healthcare subjects. Again this will include both Custody Sergeants and Detention Officers.
TVP has NHS L&D clinicians imbedded within its custody suites. The force has seen an increase in its coverage with Aylesbury custody now receiving imbedded clinicians from 2020 and a plan to increase the coverage at Milton Keynes custody to include weekends later this year. TVP now sees clinicians physically based in all suites with the exception of Newbury (due to a lack of arrest footfall). The hours worked by the clinicians differ, again due to a difference in footfall between the suites with some receiving a 0800/1600 coverage and others a 0800/2000 coverage. Technology is also due to be trialled to allow assessments to take place remotely with the use of tablets. This coverage will be reviewed in 2020 to ensure that it is correct for each suite’s differing arrest footfall."]