Source · IOPC Learning Case

Teenager took his own life after calling police for assistance – Kent Police, May 2020

Kent Police Ref: 2020/135676 Recommended 27 Jul 2021 Response due 21 Sep 2021

Death and serious injury Welfare and vulnerable people

Case background

Text published by the IOPC.

On 6 May 2020, a 17-year-old teenager made a call to the police saying he intended to take his own life and asked the police to send someone to pick him up. This call was abandoned before he provided his location. The following day, he was found dead in Dunorlan Park, Tunbridge Wells.

Our investigation followed a mandatory referral from Kent Police about the contact staff had with the boy and the force’s response to the call. There was initially an indication one police officer and five members of police staff individually may have breached the police’s standards of professional behaviour.

We analysed the abandoned call he made to the police and the calls returned by Kent Police, along with all other documents created during the incident. Kent Police policy, guidance and legislation were examined along with its training material. All the individuals under investigation were interviewed by us. We also obtained numerous witness statements.

We concluded our investigation in December 2020.

Our investigation found no officer or staff member had a case to answer for misconduct or should face unsatisfactory performance proceedings. We have recommended a Practice Requiring Improvement process for a police officer and two police staff members.

Our findings were shared with the family, Kent Police and HM Coroner, for the purpose of assisting with the inquest hearing into the teenager’s death.

The inquest concluded in May 2021 and his death was recorded as suicide.

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. We identified areas of organisational learning during this investigation and progressed these under Paragraph 28A, Schedule 3, Police Reform Act 2002. These are around gradings of threat to life calls made to the Police and the system they use to trace the location of callers. Kent Police accepted our recommendations.

Recommendations and responses

4 indexed

Recommendation 1

Link to recommendation · Accepted

Addressed to: Kent Police

Linked bodies: Kent Police

IOPC recommendation

The IOPC recommends that Kent Police provide clarity within their policies and guidance in relation to the grading of and dispatch to incidents where a ‘threat to life’ has been received by the control room, but no exact location is available.

This follows an IOPC investigation where an unknown male made an abandoned call to police stating he was about to kill himself. The call was initially graded as immediate by the control room believing they had a location for the male. However, when others went on to deal with the incident they did not believe the results showed a defined enough location to attend and downgraded it to high.

There appeared to be some confusion between the different control room staff over grading for a life at risk.

Response published by the IOPC

Do you accept the recommendation?

Yes

Accepted action:

Action Taken By Kent Police: This has been added to FCR Guidance, known as PAGES and briefed to staff. PAGES now states: 9. N.B: An Immediate grade incident must NOT be downgraded due to

- There is no 'location' to deploy to - if the risk is such that an 'immediate response' [action] is necessary to mitigate risk (ORC 14/5/20)
- There being a lack of a patrol to attend
- Inability of the attending driver to utilise Urgent Duty Driving (UDD)
- The passage of time between the initial call and the availability of a patrol to be dispatched or their arrival at scene (but the attending patrol must be advised of the full circumstances)

Check the original case on the IOPC website

Recommendation 2

Link to recommendation · Accepted

Addressed to: Kent Police

Linked bodies: Kent Police

IOPC recommendation

The IOPC recommends that Kent Police should ensure that where computer systems are upgraded and updated, that default settings are checked and the operators of those systems are made aware of the changes to settings before use.

This follows an IOPC investigation where it became apparent that the mapping software the Force Control Room (FCR) were using had been updated / upgraded quite some time ago and users of the software had not been made aware of changes to the default settings. Therefore users of the software were not obtaining the most accurate results possible unbeknown to them.

Response published by the IOPC

Do you accept the recommendation?

Yes

Accepted action:

Action Taken By Kent Police: The map produced at the time of the incident showing the location of the caller (who had made a threat to end his life) was not as accurate as it could have been if the mapping software was being used to its full functionality. The new mapping software mentioned by the IOPC did not default automatically on users’ systems, but had to be subject of user selection. Staff were not aware of the full functionality of the new mapping software. After the death and the identification of this issue, the functionality of the new mapping software was briefed to staff to ensure that all staff understood it and it is selected on their systems. Subsequently it was added as the permanent default setting on all users’ systems. Kent Police systems are subject to upgrades by external software providers. Further system upgrades are subject to testing by FCR's Operational Support Unit to identify any issues after upgrades and updates, and any new upgrades will take the mapping software’s functionality into account. Checks will be made to ensure that any existing functionality that is required remains in place when an update occurs, and that any new functionality added by the update is understood by staff and set as a default setting where appropriate. This issue remains under constant review to ensure the system remains fit for purpose with full functionality being available and understood by users after any upgrades.

Check the original case on the IOPC website

Recommendation 3

Link to recommendation · Accepted

Addressed to: Kent Police

Linked bodies: Kent Police

IOPC recommendation

The IOPC recommends that Kent Police should add 'consider sending the suicide text' to the list of actions for the dispatcher on the PAGES guidance 'Suicide - Threats or Attempts to commit'. The suicide text is a text message which can be sent direct to a person who has made a threat to take their own life, and signposts various charities to contact. Sending this text message should be a consideration for the dispatcher depending on the specific circumstances of the incident along with the list of other actions for them to complete which is present on this guidance, when treating the incident as a Suicide threat or Attempt to commit.

This follows an IOPC investigation where a text message was not sent by Kent Police to a suicidal caller until over four hours later after he called, during the time Kent Police were trying to re-contact him.

Response published by the IOPC

Do you accept the recommendation?

Yes

Accepted action:

Action Taken By Kent Police: The following has been added to dispatcher actions on PAGES and briefed to staff: Dispatcher actions

- Assess information
- Deploy as appropriate
- Consider silent approach
- Ensure that Dispatch Team Leader and Force Incident Manager are aware.
- Inform Duty Inspector
- Ensure STORM reflects all actions taken
- Consider (as applicable) other services: SECAmb, KFRS, Network Rail, BTP, Coastguard etc.
- Consider sending 'Suicide Risk' FCSMS message if appropriate.

Check the original case on the IOPC website

Recommendation 4

Link to recommendation · Accepted

Addressed to: Kent Police

Linked bodies: Kent Police

IOPC recommendation

The IOPC recommends that Kent Police should add 'consider sending the concern for safety text message’ if one has not be sent by the call taker' to the list of 'dispatcher actions ' on the PAGES guidance 'Concern'. If a location is identified for the caller the incident will be transferred from the call taker to dispatch. If dispatch are subsequently unable to locate the caller and they are trying to get in touch with them, it may be beneficial to send the caller a text message (if they can see one has not been previously sent by the call taker). This text message would notify the caller there is a concern for their safety and provide non-emergency contact numbers for them to assist in the situation. Sending this text message should be a consideration for the dispatcher depending on the specific circumstances of the incident along with the list of other actions for them to complete which is present on this guidance, whilst treating the incident as a concern for safety.

This follows an IOPC investigation where a text message was not sent by Kent Police to a suicidal male until over four hours later after he called, when they were trying to get bck in touch with the male.

Response published by the IOPC

Do you accept the recommendation?

Yes

Accepted action:

Action Taken By Kent Police: The following has been added to PAGES for the dispatcher to consider sending a text message to the person for whom there are concerns, and briefed to staff: Dispatcher actions - Concern calls Dispatchers should consider sending a text message to the person for whom there are concerns.

Check the original case on the IOPC website