Death of 37 year old male in Edinburgh
On the evening of Saturday 14 September 2013 the body of a 37 year old man, who lived alone, was found by police in his Edinburgh home after officers of Police Scotland forced entry. There were no suspicious circumstances. The date and time of death has not been determined.
The man suffered from mental ill health, had a history of self-harming and had a recent manic episode. He also had a heroin addiction and had been treated on a compulsory basis as a mandatory in-patient at the Royal Edinburgh Hospital by order of a court.
On 6 September 2013 the man was released from hospital on weekend leave to reside with his mother. On 7 September he left his mother's home and, when he did not return by the following day she reported him missing to hospital staff. On 8 September 2013 the hospital reported the man missing to Police Scotland and he became the subject of a missing person enquiry by E Division. The man was initially assessed as a Low Risk missing person (there is no apparent threat of danger to either the subject or the public) and limited enquiries were undertaken by police to trace him. Following a review by Police Scotland several days into the missing person enquiry the risk was raised to medium (The risk posed is likely to place the subject in danger or they are a threat to themselves or others). All police supervisors involved in the enquiry were of the opinion that the level of assessed risk and concern did not justify forcing entry to the man's home.
On the evening of Saturday 14 September 2013, following significant concerns raised by the man's mother, Police Scotland forced entry to his home and found him dead within. It was evident that the man had been dead for some time.
The overall management and response by police to the missing person enquiry was referred to the PIRC for independent investigation. PIRC investigators interviewed family members, medical professionals and staff, staff from other agencies, obtained and examined statements from police officers, listened to audio recordings, examined police command and control and other records and visited the scene.
Following investigation the PIRC identified shortcomings and failings by the police in their management and response to this incident. The overall conclusion of the PIRC is that:
- From the information available to Police Scotland, it should have been apparent that the man was a vulnerable person;
- The missing person enquiry was classified as a low risk. It should have been immediately graded as a higher risk;
- Following significant concerns raised by the man's mother on 10 September 2013, Police Scotland should have forced entry to his home;
- There was a lack of clear ownership and accountability in respect of the missing person enquiry. Numerous police supervisors merely endorsed the determinations of their predecessors without undertaking a critical examination of all the available information and evidence.
- The majority of Police Scotland supervisors followed the legacy Missing Person Protocol between the REH and legacy Lothian and Borders Police Force Joint Protocol (E Division Protocol) exclusively, with little reference to the Police Scotland Missing, Wanted & Found Persons, Abscondees and Escapees Standard Operating Procedures (Police Scotland SOP). There are crucial differences between these two documents;
- Prior to the man going missing, there were repeated failures to update the Police National Computer (PNC) with appropriate warning signals, which would have informed the missing person enquiry;
- Officers failed to obtain all available and relevant information following the initial missing person report and subsequently did not undertake thorough enquiries in line with the Police Scotland SOP;
- A search of the man's mother's address was not carried out as outlined in the Police Scotland SOP;
- Officers failed to follow the E Division Protocol with the REH and ensure that medical staff undertook a search of appropriate areas of the REH;
- The initial grading of the incident on the Storm Command & Control system should have been Grade 2 (Priority Response) or Grade 3 (Standard Response), both of which would normally be utilised for missing person reports and require police attendance, and not Priority 5 (incidents that can be resolved by telephone or by some other means which do not require police attendance);
- No enquiries were conducted in relation to a bus pass reported to be in possession of the man;
- Some information passed to E Division Area Control Room staff in writing and by telephone was not fully or accurately recorded on the command and control system and was not therefore available for consideration of action by police supervisors;
- Police Scotland failed to take up an offer from a Mental Health Officer to progress a search warrant for the man's home under the Mental Health (Care and Treatment) (Scotland) Act 2003.
Following examination of all the available evidence and information in respect of this investigation the Commissioner recommends to Police Scotland that:
- Review the E Division Protocol and ensure that it is brought into line with national missing person procedures;
- In all instances of persons being reported missing from the REH, a physical visit to the hospital should be made by Police Scotland to ensure all appropriate background information is obtained;
- It consider providing additional training to appropriate supervisory ranks in E Division in the management and conduct of missing person investigations;
- It emphasise to ACR staff the importance of accurately recording all available information on missing persons and make that information available to operational officers;
- It should review the actions of the officers involved and examine the wider issues raised by this investigation.