Commissioner releases findings on PIRC investigation into police missing person case

On Thursday 24 September 2015, the body of 88-year-old Janet McKay was found in the area of Rothesay Docks, Clydebank.

Mrs McKay, who had been missing from her home in Glasgow since Wednesday 16 September 2015, suffered from a number of health problems including advanced dementia. It could not be determined when, over the eight day period she was missing, Mrs McKay died.

Circumstances leading to the PIRC investigation

Janet McKay was reported missing to Police Scotland on the afternoon of 16 September 2015. Given her advanced age and deteriorating health she was immediately classified as a 'high-risk' missing person, meaning that because of her vulnerability there were substantial grounds for believing that she was in danger and that the risk posed was immediate.

Police Scotland instigated a full-scale missing person enquiry, including ground and air searches, house-to-house enquiries, searches of previous known addresses and places of work, media alerts, and notifications to bus and taxi companies. Mrs McKay's body was discovered eight days later, on 24 September 2015.

The Crown Office and Procurator Fiscal Service (COPFS) instructed the PIRC to investigate how Police Scotland had managed the missing person investigation because of what appeared to be a number of procedural and investigative shortcomings. In particular, these included the apparent failure to:

  • Act upon a number of vital investigative leads.
  • Follow effective briefing and debriefing processes that would keep officers informed of new information and developments during the enquiry.

Findings of the PIRC investigation

As part of its enquiries, PIRC investigators interviewed members of the public, police officers and staff. They examined police statements, CCTV evidence, telephone calls and police radio transmissions. Investigators scrutinised police files including missing person forms, command and control logs, standard operating procedures and policies, and other evidence gathered by the police.

Following investigation, the Commissioner submitted her report to COPFS and now publishes a summary of her findings.

The Commissioner found that Police Scotland reacted swiftly to the report of Mrs McKay as a missing person. It correctly assessed her as a high risk missing person and allocated significant local and specialist resources for the duration of its missing person enquiry. Nevertheless, the PIRC investigation identified a number of procedural and investigative failings in how Police Scotland managed its enquiry.

a) Procedural failings

  • Many of the police officers involved in the enquiry had not read or were not fully aware of guidance contained in Police Scotland's Missing Person Standard Operating Procedures (SOP) and therefore did not follow standard missing person enquiry procedures.
  • The form used by Police Scotland to record information about the enquiry had a number of weaknesses, including the inability to quickly identify lines of enquiry that had not been completed.
  • Although Police Scotland conducted a timely search for Mrs McKay, officers did not properly record all the information available to them, in particular:
  • Officers failed to obtain initial statements from key witnesses or to accurately record some of the initial information they had obtained.
  • A number of supervisory officers failed to properly record various items of information on the missing person enquiry form.
  • Some items of evidence taken by police officers were not always properly processed or recorded.
  • There were other procedural failings in Police Scotland's management of the investigation which, while they may not have materially affected the time taken to find the elderly woman, are shortcomings that Police Scotland should resolve without delay.

b) Investigative failings


  • Police Scotland held relevant information about Mrs McKay on its Vulnerable Persons Database (VPD), but it was several days before police supervisors were notified of information that:
  • On previous occasions when Mrs McKay had gone missing she had used buses.
  • Earlier that year she been found in a confused state on a bus bound for Clydebank.
  • Officers failed to take a statement from a key witness, Mrs McKay's home carer, who was known to have visited the elderly woman's home on the day she went missing and who would have been able to describe what Mrs McKay had been wearing.
  • On 17 September 2015, one day after the elderly woman was reported missing, police supervisors failed to act promptly in response to a reported sighting of Mrs McKay on the day she had gone missing.
  • On 18 September 2015, two days after the elderly woman went missing, police officers failed to inform a relevant officer or supervisor of significant information about Mrs McKay being seen by another witness on the day she went missing. On 22 September 2015, when this failure was eventually recognised, there was a further delay when an officer failed to pass on the address of this witness to other officers, thus causing further delay in obtaining a statement from the witness.
  • On 19 September 2015, three days after the elderly woman went missing, a witness told Police Scotland that he had seen Mrs McKay boarding a bus to Clydebank near to her home. Despite holding information on its VPD about Mrs McKay's previous use of buses, and specifically her use of a bus to Clydebank, Police Scotland did not follow up this vital information until six days after the woman went missing, on 22 September 2015.
  • Although Police Scotland did carry out enquiries with local bus companies, the enquiries were not as focused and timely as they should have been.
  • Some briefings given by police supervisors to officers about lines of enquiry were not adequate.
  • Some police supervisors failed to check that lines of enquiry had been properly completed - for example, failing to obtain relevant CCTV footage showing the elderly woman on board the bus to Clydebank on the day she went missing.


1.      That, in order to effectively manage and co-ordinate missing person enquiries, at the start of all investigations involving high-risk, vulnerable missing persons Police Scotland:

  • consider setting up an electronic or manual Major Incident Room overseen by an appointed senior investigating officer, and
  • follow standard and well-established major incident management protocols.

2.      That Police Scotland ensure that all its officers and staff are fully aware of the procedures to be followed in high-risk missing person enquiries.                                                           

3.      That Police Scotland examine and take action on the failings highlighted by this investigation and put in place measures, if it has not already done so, to ensure that such failings do not happen again in future high risk missing person enquiries.                                                                                                       

4.      That Police Scotland ensure that any items seized as evidence in missing person enquiries, particularly CCTV evidence, are properly recorded, prioritised and where identified as important, reviewed immediately.                                                                        

Additional note 

  • At the same time as submitting her report to COPFS the Commissioner also shared her findings with the Chief Constable. This was to enable Police Scotland to take immediate corrective action to ensure that future missing person enquiries will not be subject to the same failings.

Commissioner quotes:

"This investigation highlighted a number of investigative and procedural shortcomings by Police Scotland in conducting a missing person enquiry for a vulnerable, elderly woman who suffered from dementia.

"I have made a number of recommendations which I have already shared with the Chief Constable, in light of this case, to enable him to put measures in place and take corrective action to prevent such failings in the future."

View this as a PDF 

<  Return to investigation reports