Death Enquiry: Officer Sent to the Wrong Address


About 0240 hours on the morning of Saturday 20 February 2016, a 52 year old woman was found dead in her house in Dumfries by police officers who had forced entry in response to calls expressing concern for the woman's safety. There were no suspicious circumstances.

Circumstances leading to the PIRC investigation

Prior to the discovery of the woman's body, at 2207 hours the previous evening the woman's daughter had telephoned Police Scotland's Service Centre and Area Control Room (ACR) at Govan, Glasgow, expressing concern for her mother's safety.

The daughter told police that the woman had not visited her home earlier that day as arranged and that she was not answering her calls or text messages. The daughter provided ACR staff with her mother's details including her name, age, physical description and her address. She also informed them that her mother suffered from depression and had previously self-harmed and attempted suicide.

The member of staff at the ACR noted the details and raised an incident on the police command and control system. However, on entering details of the mother's address, the ACR staff member did not spot that as a result of a known issue between the Gazetteer mapping system and the command and control systems used by Police Scotland, the address was transposed in such a way that it was misinterpreted, resulting in officers being sent to the wrong house.

Having correctly determined that the call was a Grade 2 incident, where there is a degree of urgency associated with police action, ACR staff instructed police officers to attend within 15 minutes. Erroneously those officers were provided with the wrong address. ACR also provided the front line officers with the name of the woman they were looking for but did not pass on her age or physical description. Additionally, information on the police system, identifying the woman as a vulnerable person, was not supplied to the attending officers.

Police officers then made their way to the wrong address and at 2235 hours roused an elderly 84 year old woman who lived there, from her bed.

The officers explained to the 84 year old woman that her daughter was concerned for her as she had failed to answer her phone. This woman told the officers that she was partially deaf, had misplaced her phone but would phone her daughter.

At that time, the officers noted the 84 year old woman's name but failed to realise that it was a different name to the person that they were looking for and they did not recognise that they had been speaking to the wrong person. The officers informed the control room that the occupant of the (wrong) address had been traced and was safe and well. They did not provide the ACR with the name of the person they had spoken to.

The police did not update the daughter who had originally contacted them expressing concern for her mother.

Over the next few hours, she became increasingly concerned about her mother's safety and she, her husband and a neighbour of the woman all phoned Police Scotland for an update on their enquiries. At that time they were assured that officers had spoken with the woman, that she was safe and well and that she would be phoning her daughter.

At 0153 hours on Saturday 20 February 2016, as the woman's daughter had not heard anything from her mother, she went to her mother's home and on receiving no reply, again phoned Police Scotland from her mother's neighbour's home. At 0206 hours, the officer who had attended the first call (at the wrong address) was sent by ACR staff firstly, to speak to the daughter, then to go to the woman's home. It was not until officers were en route to the daughter at the woman's neighbour's home that the mistake in attending the wrong address was discovered.

At 0240 hours police officers assisted by personnel from the Scottish Fire and Rescue Service, forced entry to the house and discovered the woman dead inside. Following a post mortem examination, the cause of death was identified as an overdose of prescribed medication. It was suspected that the woman had taken an accidental overdose. Medical opinion was also obtained on the likely time of death, which was suggested to be between 6 and 24 hours before the woman was found.

Crown Office and the Procurator Fiscal Service (COPFS) instructed the PIRC to investigate the circumstances of the police involvement in the death, and in particular to:

  • Establish a time of death and narrow the parameters of the time of death as far as possible to help determine whether it was already too late for Police Scotland intervention, even if they had attended the correct address on the first occasion
  • Investigate the reasons why the Police Gazetteer system produced an incorrect address
  • Investigate the actions of Force Control and in particular the information they provided to officers about the address, the deceased and her vulnerability and whether they should have called back the woman's daughter following the officers first house visit
  • Investigate the actions of the attending officers and in particular whether they should have confirmed the details of the elderly lady they spoke to and the apparent discrepancy in address

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, Command and Control (STORM) logs, police reports, telephone recordings, briefing papers, Scottish Police Authority photographs and Police Standard Operating Procedures. They also seized productions.

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

The Commissioner found that it is likely that the woman died between 1200 hours on Thursday 18 February (when she was last seen alive) and before 0830 hours on Friday 19 February 2016, (which is the outside limit of time parameters provided by the pathologists). On the basis of that information, it is therefore likely that when Police Scotland were initially contacted at 2207 hours on Friday 19 February 2016, the woman was already dead, however the Commissioner raised concerns regarding the Police Scotland Gazetteer system and failings in the actions of both Area Control Room staff and the attending officers.

The Commissioner found:

Police Gazetteer System

Difficulties with the transposition and interpretation of some addresses was/is a known problem with the Police Scotland ACR Gazetteer system.

Actions of Area Control Room Staff

That ACR staff did not provide relevant available information to officers attending the call, including the age or description of the woman they were looking for.

That confusion appears to have existed between ACR staff and attending officers as to who had responsibility for updating the woman's daughter.

Actions of the Attending Officers

That the officers who attended the call did not undertake basic checks to confirm that the elderly woman at the wrong address was not the woman about whom concerns had been expressed and had they done so, then the series of subsequent errors, including informing the woman's daughter that her mother was safe and well, would not have happened.

Additional note

The Commissioner notes that in this case, as in a number of other PIRC investigations, there was disagreement between ACR staff and operational officers as to who had ownership and responsibility for undertaking additional enquiries and in particular, who had responsibility for updating those who originally report the incident. This has often led to neither contacting the reporter and missing the opportunity to identify errors sooner.

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

Recommendations

The Commissioner recommends that

  • Police Scotland take steps to address the known fault in Police Scotland's ACR Gazetteer system.
  • Police Scotland ACR staff ensure that front line operational officers are provided with all relevant available information.
  • Police Scotland examine issues of command and control in regard to incident management and provide clear guidance to ACR staff and operational officers on who should assume responsibility for undertaking particular lines of enquiry and investigation including responsibility for updating reporters. These details should be recorded in the police command and control system.

Commissioner quotes:

Kate Frame, Police Investigations and Review Commissioner, said

This case highlights the need for Police Scotland to ensure that all available relevant information is accurately transmitted to front line operational officers and for them to act on it appropriately to achieve the service the public expect.

It is deeply troubling that despite issues having been identified between the Gazetteer mapping system and the command and control systems used by Police Scotland before the incident, these issues, which in certain circumstances could prove to be critical, were not resolved.

Although training had apparently been put in place until a permanent fix could be found, confusion remained and in this instance ACR staff misinterpreted the woman's address which resulted in officers going to the wrong house.

Additionally, whilst the woman's daughter provided the ACR staff with details of her mother's age and description, the fact that this information was not provided to the attending officers, prevented them quickly identifying that the 84 year old woman who they spoke to at the wrong address, was not the 52 year old woman that they were looking for.

It is disappointing that the officers who attended at the wrong address, do not appear to have appreciated that when they spoke to the 84 year old woman, her name, which they noted, did not match the name of the 52 year old woman whose name they had been given.

This case demonstrates again the need for clarity within Police Scotland as to who assumes responsibility for updating those who report incidents and are well placed to identify whether the correct information has been acted on at the earliest opportunity.

Whilst I recognise from the medical evidence obtained in this particular case that it is likely the 52 year old woman was dead by the time the alarm was raised, it does not diminish the particular failures identified or the additional distress caused to the woman's family."

To view this document as a pdf please click here.

<  Return to investigation reports