Failures in Call Handling & Incident Management in Respect of the Death of a Vulnerable Person in Edinburgh


On 23 March 2016, the body of 37 year old Andrew Bow, who suffered from Asperger's Syndrome and had learning difficulties, was found in his home in a block of flats in Edinburgh. Despite a post mortem, the cause of his death could not be determined.

Andrew Bow was last seen on 12 March 2016 when police officers attended Holyrood Park, Edinburgh, in response to a call from a member of the public expressing concern for Andrew Bow, who was acting strangely. On arrival police officers found him in a confused and paranoid state and took him to the Royal Edinburgh Hospital where he was examined by the Mental Health Assessment Team who deemed him fit to go home. He was taken home by medical staff and the police. This incident was recorded on police systems.

Enquiries revealed that Andrew Bow's bank card was last used on 15 March 2016 indicating a strong possibility that he was alive at that time.

Circumstances leading to the PIRC investigation

On 15 March 2016, one of Andrew Bow's neighbours reported to the City of Edinburgh Council that the windows of Andrew Bow's flat were broken. This neighbour provided an incorrect address for Andrew Bow's flat to the Council. This error appears to have arisen due to the confusing street signage and house numbering system at the flats. Council staff considered that the matter required police investigation and reported the matter to Police Scotland. The police officer who received the report did not raise an incident report or have officers attend at Andrew Bow's flat to conduct enquiries.

About 5.25pm on 21 March 2016, a local shopkeeper saw that the windows of Andrew Bow's flat were broken and reported the matter to Police Scotland via the 999 emergency telephone system. The shopkeeper told the police about the confusing house numbering system at the block of flats and offered to stay at his shop to show officers the exact location of the flat. The call was handled by Police Scotland's Area Control Room (ACR) at Bilston Glen. Despite the call being graded as requiring officers to be sent within 40 minutes, ACR staff did not send police officers to the call. At 10.54pm, some five and a half hours after the 999 call, ACR staff attempted to contact the shopkeeper to check his availability to assist officers. On receiving no response, ACR staff again decided not to send officers to the incident at that time and updated their system to show that no resources were available.

About 9.45am the following day, 22 March 2016, the shopkeeper again contacted the ACR at Bilston Glen via the 999 system to raise his concerns and again offered his assistance to show officers the exact location of the flat. Despite linking the call from the previous day to this report, ACR staff again did not send officers to Mr Bow's flat and again determined that no police resources were available to be dispatched.

About 6.31 pm that day, 22 March 2016, another neighbour of Andrew Bow telephoned the ACR to report her 'concerns' for his welfare. She told ACR staff that Andrew Bow suffered from mental ill health and that the windows of his flat were broken. ACR staff saw the two 'un-actioned' earlier 999 calls and saw that they contained "concerns for the occupant", that he may have "hurt himself" or "committed suicide". Again ACR staff did not send police officers to Mr Bow's flat. It does not appear that ACR staff linked the reports to the incident in Holyrood Park on 12 March 2016.

On 23 March 2016, a local policing sergeant, having read details of the incidents on Police Scotland's command and control system, decided to send police officers to Andrew Bow's flat. At 9.30am police officers forced entry to the flat and found Andrew Bow dead inside. Following a post mortem examination, pathologists could not provide an estimated time, date or cause of death.

On Thursday 24 March 2016, the PIRC was instructed by the Lord Advocate, in terms of Section 33A(b)(ii) of the Police, Public Order and Criminal Justice (Scotland) Act 2006 as amended, to investigate,

'The circumstances surrounding the police handling of these calls from the first call at approximately 1735 hours on Monday 21 March 2016, until the call was responded to at 0930 hours on 23 March 2016 and its aftermath.'

Findings of the PIRC investigation

PIRC investigators interviewed members of the public, police officers and staff at the Bilston Glen ACR. They also examined police statements, telephone calls and police radio transmissions. Investigators scrutinised police resource levels for the City of Edinburgh to determine the availability of officers to attend calls, examined command and control logs, standard operating procedures and policies and other evidence.

Following investigation, the Commissioner submitted her report to the Crown Office and Procurator Fiscal Service (COPFS) and now publishes a summary of her findings.

Andrew Bow was known to police as a vulnerable person and was recorded on Police Scotland's Vulnerable Persons Database.

On 12 March 2016, police officers attended Holyrood Park, Edinburgh, in response to a call from a member of the public expressing concern for Andrew Bow, who was acting strangely. On arrival police officers found him in a confused and paranoid state and took him to the Royal Edinburgh Hospital where he was examined by the Mental Health Assessment Team and subsequently taken home by medical staff and the police. This incident was recorded on police systems.

Andrew Bow died sometime between 12 March 2016, when he was last seen alive and 23 March 2016, when his body was discovered. However, his bank card was used on 15 March 2016 and therefore, there is a strong probability that he was alive at that time.

The police officer receiving the first report of broken windows at Andrew Bow's flat on 16 March 2016 did not raise an incident report, which would have provided an opportunity for police to send resources to check on Andrew Bow's welfare or to see that all was in order.

Despite receiving three calls between 21 and 22 March 2016 from members of the public, expressing concern for Andrew Bow's welfare or reporting damage to his house, staff at Police Scotland's Area Control Room (ACR) at Bilston Glen failed to send officers to deal with the reports. Whilst these calls were graded as Grade 3 calls and merited a response requiring officers to be sent within 40 minutes, reports of 'concerns for a person' merit a higher priority response, requiring officers to be sent within 15 minutes of the report.

Police officers and civilian staff working in the ACR stated when interviewed that it was not uncommon for Grade 3 calls, which require police officers to be sent within 40 minutes, to remain un-actioned for days before being referred to the relevant police division for action. Some ACR Sergeants stated that a significant percentage of Grade 3 incidents are not dispatched within required timescales.

ACR staff stated to PIRC investigators that there were no resources to send to the calls at the time they were received. This was found to be inaccurate. PIRC enquiries and an internal Police Scotland review showed that Community Police officers were available to attend the calls. These officers were not sent by ACR staff and it appeared that there was a significant reluctance by ACR staff to send Community Officers to calls.

As it is not possible, from medical evidence, to establish precisely when Andrew Bow died, it is not known whether an earlier response by Police Scotland could have led to him being found alive and his life saved.

Recommendations

  •  Police Scotland take action to improve the handling and management of calls dealt with by staff at their Area Control Room (ACR) at Bilston Glen.
  •  ACR staff ensure that they use all available operational resources to send to priority calls, particularly those expressing concern for the safety or security of the public.

Commissioner Quotes:

Kate Frame, Police Investigations and Review Commissioner, said:

"This investigation identified a number of failings by Police Scotland over a seven day period, in their response to repeated reports of concern for Andrew Bow, who suffered from Asperger's Syndrome and learning difficulties."

"It is particularly concerning that despite several members of the public contacting the police to express their concerns, Police Scotland appear to have taken no action in relation to the first approach and thereafter in response to the subsequent calls, failed to dispatch officers who were available, timeously, to investigate."

"Whilst there may have been confusion in identifying the correct address from the original report, the person who contacted the police on the second occasion offered to remain at his premises and point out the flat to officers. Had that opportunity been taken, the police would have been able to identify the deceased's flat and investigate matters sooner."

"Since it has not been possible to establish precisely when Andrew Bow died, it is not certain whether an earlier response by police could have led to him being found alive and his life saved."

"I have made a number of recommendations to the Chief Constable to ensure the handling of calls by staff at Bilston Glen are managed better, within the required timescales and that all available officers are sent to priority calls, especially those of concern about a vulnerable person."

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