Police welfare check on a woman prior to her death – Durham Constabulary, October 2017

In October 2017, a woman was reported missing by her sister. Durham Constabulary were told that she had left her ex-partner’s house, having potentially consumed her ex-partner’s diabetes medication and was likely to have gone to her new partner’s home. Her new partner was found and an officer was sent to do a ‘safe and well’ check. The officer did not wake the woman or speak to her and the missing person report was subsequently closed. The woman was taken to hospital later that day and subsequently died from a suspected overdose of prescription medication.

During the investigation, we interviewed several officers under notice for misconduct, including those responsible for risk assessments and incident grading and the officer who was deployed to undertake a welfare check on the woman.

Our investigators also considered the incident log and missing persons’ report as well as force policies in relation to deployment and missing persons. The investigation found a number of missed opportunities in relation to communication, risk assessments and adherence to force policies.

Our investigation concluded in December 2018, but we waited for all external proceedings to conclude before sharing our findings.

An inquest was held in May 2024.

During our investigation, we identified failings for two officers that were not sufficiently serious as to justify disciplinary action (at least a written warning) and instead, were addressed through management action.

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, the investigation has not identified any learning.