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Suicide after calls to police raising issues about:
· Unrealistic expectations of ambulance service
· Staff attitudes to threats of suicide
· Grading and downgrading of calls
· Use of ‘no resources’ button
· Use of unsolicited messages
· Training of staff in communications centre
· Provision of information to family
Overview of incident
Mr A, a man of 38, worked as a bricklayer. In the first part of 2005 he was building an extension and developed a relationship with Mrs B, the wife of the couple of the house. Mrs B ended the relationship at the end of the year. This prompted threats by Mr A to kill himself, but the relationship resumed when Mr and Mrs B separated. However, in May 2007 Mrs B ended the
relationship for good.
Around the beginning of June 2007, Mr A called Mrs B and wrongly accused her of being back with her husband. Around this time, a member of the public called 999 when Mr A was found lying in the middle of the road; the police officers who attended helped him home. Although he received help from an ambulance crew because of a minor injury to his head, he did not recall what had happened as he had drunk a lot.
Shortly after midnight, nearly three weeks later, an ambulance went to Mr A’s home after a call from Mrs B who said he had threatened to kill himself. The ambulance service, concerned for the safety of the crew, called the police to ask for help but did not say why it was needed. The call handler in the Customer Contact Centre (CCC) did not ask why either. The call was logged
as ‘emergency Grade 1’ because it involved danger to life but, although no check on resources had been made, the call handler recorded that no appropriately trained resources were available. In fact, officers were available to attend.
A police operative called back to ascertain why police help was wanted but decided police would not attend as no specific threat had been identified. Mrs B had told the ambulance service that Mr A was not violent, did not have weapons and it was only because Mrs B was not calling from Mr A’s home that the ambulance crew thought there could be a risk to the crew.
The operative, who took the view that people very rarely act on threats to commit suicide, suggested the crew assess the situation on arrival and downgraded the incident from Grade 1 to Grade 4. There was no record of obtaining authorisation from his team leader or recording the reason for the decision, as the user guide for the system required.
The ambulance crew arrived at Mr A’s home at 0.54am and found a light on and the front door locked. They tried knocking at the door and shouting at the front and back but without success.
They called the police for help at 0.56am, expressing concern for Mr A’s welfare. The call handler updated the incident log and sent an unsolicited message (UM) - an electronic message used to pass information from the CCC to the Force Control Room (FCR) (the other part of the Force communications centre). There was no facility on the system to show the message had been received and it had been clear for some time that UMs were often missed or not read. No action was taken in response to this message.
The ambulance staff called again at 1.12am and another UM was sent to the FCR, commenting that the incident needed to be upgraded. A member of staff upgraded the incident to Grade 2 (concern for welfare) at 1.20am but not to Grade 1 (danger to life) as he did not read the full message and missed the suicide threat. After another call from ambulance staff, at 1.28am police officers were sent. The incident was upgraded to Grade 1 five minutes later.
Meanwhile, because of the delay in obtaining police help, the ambulance crew decided to force entry. When they succeeded at 1.41am they found Mr A hanging from a wardrobe door handle. He was dead. The police arrived a few minutes later.
There was no record of the family liaison officer notifying the family that the body was being moved to another town for the post mortem. It was therefore unclear whether he did or whether the family found this out when ringing the coroner’s officer.
The coroner’s officer sent the family a number of ‘Interim Certificate of the Fact of Death’ notices which gave the wrong address for Mr A. When she told them where the death would be registered she gave the wrong town. She also told them the burial certificate could be collected from the police station but they found on arrival it had - as was normal practice - been collected by the undertaker.
Type of investigation - IPCC Independent Investigation
Recommendations
Local
1. The initial grading of the call was correct on the information provided and complied with the Force’s incident graded response policy. However, further information should have been obtained to establish that the ambulance service was requesting police officer attendance because the original caller was not at the address. To expect the police to attend incidents in such circumstances is unrealistic in view of the limited police resources available. The different expectations each service has in relation to what levels of response the other can deliver is a matter of serious concern. These concerns were highlighted to both the Force and the local ambulance service to allow them to address the situation as quickly as possible.
2. The manner in which the incident was downgraded from Grade 1 to Grade 4 was a significant failing which had repercussions throughout the incident. The call handler downgraded the incident because there were no appropriately trained resources available to deal with it at that time. However, once the incident was downgraded it was not given the priority it needed when further information was received.
· The authority of a supervisor should be obtained to downgrade an incident and the incident log should be updated to include the name of the person and the rationale for the downgrade.
· The Force’s incident graded response policy should be revised to include this procedure for downgrading incidents.
3. The Force’s Key Performance Indicators (KPIs) provided time limits in relation to the deployment of police resources. Pressing the ‘no resources’ button on the incident log in effect stopped the clock in relation to these targets. The call handler was aware that before pressing the button, she should inform a supervisor but she did not always have time to do
this. The ‘no resources’ button should not be used unless the availability of resources has been checked.
4. The call handler who took the call from the ambulance crew when they arrived at Mr A’s house knew there was concern for his welfare but nonetheless used an unsolicited message (UM) to inform the FCR. UMs should ‘pop up’ in a Windows type format on the
visual display units in the FCR and remain visible for ten seconds. However, since the system was upgraded in late 2006, the ‘pop up’ facility did not work and this situation was not rectified until July 2007. Concerns were raised in relation to UMs being missed or not read by the FCR in both February and March 2007. The user guide for the system states ‘Unsolicited messages should only be used for business related matters. All UMs should be marked as priority. Staff receiving UMs should acknowledge them promptly. Acknowledgement of UMs is confirmation that you have acted upon the information contained in the UM or ensured that a named colleague has acted upon that information. A UM should be sent to the relevant desk in relation to
immediate actions required on a Grade 2,3 or 4 incidents transferred to that desk.’ The flaw in this statement is that there was, and had been for some time, clear evidence that UMs were either missed or not read; the reality was no one was monitoring their use. There was no facility to show the message had been received and was being acted upon.
Neither was there a facility on the system to audit trail UMs to show if they had been read
and by whom. This is a significant weakness.
· UMs are an inappropriate means of communicating critical or urgent information from the CCC to the FCR. The use of UMs for the transfer of time critical operational information should cease until such time as upgrades are made to the command and control system to prevent them being cleared until they are either acknowledged or acted upon. The telephone should be used instead.
· The Force’s incident graded response policy should be revised to include the procedure for transferring information from the CCC to the FCR
5. It is of concern that staff working within the FCR make decisions regarding the deployment of officers without fully understanding the situation they are deploying them to, in this case a threat of suicide. Moreover, personal attitudes that people are unlikely to act on threats of suicide are in conflict with the Force’s policy. The Force should address these issues
urgently.
6. It was clear that no risk assessment had been carried out by the FCR. In order to properly assess the risk, which in turn would assist in the correct grading of incidents, the Force should devise a dynamic risk assessment matrix. This should be available to communications centre staff to assist in the deployment of resources to incidents in which there is a threat to life. This should be readily available on the relevant system which FCR staff could use in order to accurately assess situations involving a threat to life in the future.
7. The temporary team leader in the FCR had received no additional training before starting in this role. At the time of this incident he was the only supervisor present in the FCR as the Inspector was on his meal break. The Force should ensure that when staff are placed in temporary supervisory positions within the communications centre they are provided with the appropriate level of training and support.
8. The Force’s incident graded response policy was due for review in November 2006. This review did not appear to have taken place. The current policy did not reflect the roles or terminology used in the CCC and FCR. The Force should revise its incident graded response and deployment policy to take account of recommendations resulting from this investigation and to accurately reflect the roles within the communications centre.
9. For a family who have lost a loved relative, it is extremely important to them that they are kept fully informed as to what is happening to the deceased person’s body. It is good practice to fully document the information provided to families to avoid any later doubt as to what was actually said. The Force should advise all family liaison officers of the need to provide accurate information to the families of people who have died, particularly in relation to the moving of the body, and to document such conversations.
10. The Force should ensure that all members of police staff employed within the coroner’s office are advised of the need to ensure that information provided to families is accurate.
To read the full learning report, click on the link below;
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