Young man found dead after being reported as suicidal - Avon and Somerset Constabulary, August 2018

At 4.17pm on 21 August 2018, a woman contacted Avon and Somerset Constabulary to report that her teenaged son had left the house ten minutes before, threatening to throw himself under a train.

The initial call was graded as a ‘priority unassessed’ response and transferred to a dispatcher at 4.23pm. This grading meant further assessment was required to determine whether officers should aim to attend within one hour or four hours. The dispatcher referred the call to a supervisor, who upgraded the call to an ‘immediate’ response, where Avon and Somerset Constabulary aims to attend within 15 minutes.

At 4.33pm, the woman’s son was struck by a train on the railway line near his home. Officers were not dispatched until after the collision had occurred

Our investigators obtained and reviewed police logs in relation to the matter, together with an audio recording of the call. They obtained accounts from Control Room staff who dealt with the call and analysed these against College of Policing and Avon and Somerset Constabulary guidance.

The investigation found that, given the timescales and the fact the precise location of the woman’s son was unknown, the police could not have realistically prevented the death even if the call had been graded as an ‘immediate’ at the outset.

Our investigation highlighted a performance issue in relation to the original grading of the call by the call handler. We considered it appropriate that this matter be addressed by management action to enable reflection and learning.

After reviewing our report Avon and Somerset Constabulary agreed with this outcome and this learning has now taken place.

We completed our investigation in December 2018 but waited until the inquest into the young man’s death had taken place in spring 2019 to publish our findings. The coroner ruled the death as a suicide.