Posted: Friday 18 August 2017

Commissioner releases findings on PIRC investigation into police response to reports of concern for vulnerable woman later found dead

The Police Investigations & Review Commissioner (PIRC) has found a number of failings in the way police responded to reports of concern for a vulnerable woman, who was later found dead.

The Commissioner has made a number of recommendations to the Chief Constable.

The daughter of the 52-year-old woman, from Dumfries, first contacted Police Scotland late at night on 19 February 2016 expressing concern for her mother's safety. She also told them her mother had previously self-harmed and attempted suicide.

However, an issue between the Gazetteer mapping system and the command and control systems used by Police Scotland resulted in the address for the woman being transposed in such a way that it was misinterpreted by Area Control Room (ACR) staff who sent officers to another nearby address.

It was more than four and a half hours later before police realised they had attended the wrong address. When they arrived at the correct location and forced entry to the house they discovered the 52-year-old woman dead inside.

The circumstances of the woman's death were referred to the PIRC by the Crown Office and Procurator Fiscal Service (COPFS).

The PIRC investigation focused on whether the 52-year-old woman would still have been alive if police had attended the correct address earlier. It also examined Police Scotland's response in relation to the report of concern by the daughter, including the actions by the ACR and the officers sent to the wrong address.

In her report to the COPFS in July 2016, the Commissioner found a series of failings in how Police Scotland dealt with the matter. In particular, the problems between the Gazetteer mapping system and the command and control systems used by Police Scotland, and the confusion between ACR staff and the officers dispatched on who should have responsibility for updating the person who reported the incident.

The Commissioner's report was shared with the Chief Constable at the time in July 2016 to allow him to take immediate action to ensure that similar enquiries are not subject to the same failings.

Following agreement with the COPFS, Commissioner Kate Frame is now able to publish a summary of her findings. Independent and effective investigations and reviews

She 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.

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."

A statement on behalf of the woman's family said:

The past 18 months have placed an incredible strain on our family as we have tried to come to terms with the loss of a loving mother and understand the tragic circumstances behind her death.

We are aware of the PIRC report and are pleased to note that a number of recommendations have been made. None of this will bring our mother back but we hope that going forward Police Scotland will look carefully at these recommendations and that valuable lessons have been learned.

As a family, we are grateful for the support we have received but would now ask for our privacy to be respected to allow us to come to terms with her loss in peace."

(Notes to Editors: The extended family have asked the PIRC to request that media outlets do not make attempts to contact them at this time)

In undertaking this investigation, 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 (SPA) photographs, Police Standard Operating Procedures and seized productions.

The PIRC investigation found that the daughter called Police Scotland's Service Centre and Area Control Room (ACR) at Govan, Glasgow, at 2207 hours on 19 February 2016. She told police her mother had not visited her home earlier that day as arranged and she was not answering her calls or text messages.

The ACR staff member took a note of the woman's name, address, age and physical description and raised an incident on the system. However, on entering the address the staff member failed to 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 address.

The call was classed as a Grade 2 incident and officers were instructed to attend within 15 minutes, but were mistakenly given the wrong address. Although they were provided with the 52-year-old woman's name, the ACR did not pass on the details of her age, physical description and the fact she was a vulnerable person. Independent and effective investigations and reviews

The Commissioner found that on arriving at the wrong address at 2235 hours, the officers roused an 84-year-old woman, who lived there, from her bed. Although they noted her name, they failed to realise it was different from the name they had been given. The officers wrongly assumed they had found the woman they were looking for and informed the ACR of this but 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 and as she became increasingly concerned for her mother's safety, she, her husband and a neighbour all phoned Police Scotland for an update on their enquiries. They were all assured the woman was safe and well and that she would be phoning her daughter.

At 0153 hours on 20 February 2016, the daughter then went to her mother's home and on receiving no reply, again called Police Scotland. Thirteen minutes later, one of the officers who had attended the first call at the wrong address was sent to speak to the daughter and while en route he discovered the mistake in attending the wrong address.

At 0240 hours police officers forced entry at the correct address and found the 52-year-old woman dead inside. Following a post mortem examination, the cause of death was identified as an overdose of prescribed medication, which it was suspected the woman had taken accidentally.

Medical opinion suggested that the likely time of death was between 6-24 hours before the woman was found.

In her report, the Commissioner identified a number of failings in the police response to the report of concern for the 52-year-old woman.

The Commissioner found that the input of some addresses was a known problem with the Police Scotland ACR Gazetteer system.

She also identified failings with the actions of ACR staff in providing relevant available information to officers attending the call and apparent confusion between them and the officers over who had responsibility for updating the woman's daughter.

The Commissioner found 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. Had they done so, the series of subsequent errors, including informing the woman's daughter that her mother was safe and well, would not have happened.

She also expressed her concern 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. In particular, who had responsibility for updating those who report the incident. This has often led to neither contacting the reporter and missing the opportunity to identify errors sooner.

The Commissioner added:

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 Independent and effective investigations and reviews 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 from quickly identifying that the 84-year-old woman who they spoke to at the wrong address was not the 52-year-old woman 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 elderly woman living there, the name she provided did not match that 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 best placed to identify whether the correct information has been acted on at the earliest opportunity."

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 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.

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