The Learning the Lessons Committee is a multi-agency committee established to disseminate and promote learning across the police service. Its members are: ACPO, APA, Home Office, IPCC, HMIC and the NPIA. The Committee produces bulletins with articles containing lessons from investigations.

Over the last 12 weeks we have looked at a number of scenarios where getting it right would very probably have saved a life or prevented an incident escalating. Here we summarise the findings. The numbers in brackets refer to the week the incident was published.

The crucial importance of information

Getting information

Several cases highlighted the vital importance of recording information from the caller correctly.

• A call handler got the location of a fall wrong and police did not find the man who had fallen until he was dead [8].

Call handlers need to consider asking the caller to remain at the scene, or contact them again:

• A caller’s offer to stay and point out a man with head injuries to the police was rejected; the police did not have an exact location, failed to phone the caller back for more information and did not find the man until he was dead [2].

Recording information

Failure to record information word for word can have serious consequences:

• A woman rang to say her husband had threatened to kill himself and she could not contact him; this was recorded as him “intimating harm”, so the call was graded ‘priority’ rather than ‘immediate’ - he was then then found hanged [6].

• Because she did not understand the term, a call handler did not record the word ‘burn’ as where a man with head injuries was behaving strangely – police failed to find him as a result and he was later found dead in the water [2].

• When a woman said her ex-husband was definitely suicidal, this was recorded as her merely thinking he could be suicidal – he was then wrongly assessed as low risk [5].

Passing information on

The right information needs to reach the right people:

• A call handler dealing with a misrouted call about a rape attack had to pass on information to the right force while keeping the caller on the line. They missed a couple of digits from the caller’s phone number [1].

This can be a particular problem on handover:

• An oncoming shift was not briefed about concerns for a man who had threatened suicide [6].

Recognising and recording risk

Once information has been obtained, being able to recognise risk and grade a call correctly is key to how it is handled.

• Police missed a high risk of suicide because the man in question had not been emotional when they interviewed him in response to an earlier call and the call handler who took the later calls did not record his ex-wife’s concerns accurately [5].

• A woman was murdered when a call handler assumed information about a threat a former psychiatric patient had made to kill his wife was for information only, as it came from hospital staff [4].

• A call handler failed to carry out a risk assessment when a man reported threats by a colleague to kill himself [7]; in another case, a dispatcher who recognised a call had been wrongly graded did not re-grade the log [8].

Using resources effectively

At busy times, resources need to be efficiently allocated to match priorities:

• The force’s system did not alert supervisors to calls approaching the time limit for a response – police did not go to a woman complaining about an aggressive drunk in her house until two hours later – she had been raped [10].

• An automatic system to notify supervisors when dispatch times had been missed was not used, with staff required to ask supervisors to view the log instead; it took nine hours before a request was made to resource a call from the Ambulance Service [11].

The value of supervision

In several cases a supervisor’s input or advice could have made a difference, highlighting the need for systems to permit this:

• A supervisor might have had experience of a caller reporting his own suicide and realised the call was not a hoax [3].

• The call handler had no way of alerting a supervisor to a man threatening suicide without disrupting the call [9].

• When hospital staff reported a man threatening to kill his wife, the call handler did not bring it to the attention of a supervisor to assess the risk [4].

Training

Lack of effective training, including refresher training, is a major factor:

• A call handler did not know how to use the mapping system that would have given her the location of a man who had fallen [8].

• A call handler with a man threatening suicide on the phone had not been trained to deal with suicidal callers [9].

Working with others

The need for forces to liaise with neighbouring forces and other agencies has featured in previous bulletins:

• Police were too busy to attend when the ambulance service requested assistance in responding to a call, leaving the ambulance service to attend by themselves [11].

• Neither the ambulance service nor the police responded to a call about an unconscious man, because both assumed the other was dealing with it [12].

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