Investigation into police contact after man dies by suicide – Gloucestershire Constabulary, November 2021

A security guard at a holiday park called the police to report that four men staying on site were involved in a fight. Two officers arrived and found a man on the floor who was distressed.

The man said that he had experienced anxiety and depression throughout his life. He said that he had self-harmed and intended to do so again that night. He said he would rather die than speak to the officers.

The officers told the man that they would not follow him around all night, before turning and walking away. They returned to their police van.

The officers found the man hanging from a footbridge 20 minutes later. The officers removed the man from the bridge and performed CPR however he was later pronounced dead.

We received a conduct referral from the force and decided to independently investigate the actions and decisions of the officers regarding their response to the incident at the holiday park, including whether they acted in line with local and national policies. Our investigators interviewed and obtained statements from witnesses, including members of the public. We also reviewed body worn video footage from the incident.

We found that the officers failed to gather information or intelligence about the man and did not treat him as a medical emergency. He was left unattended in a mental health crisis, with officers failing to request assistance from the mental health triage team. We also found that one officer used language that was dismissive.

We concluded there was no indication that a person serving with the police committed a criminal offence, but the officers had behaved in a manner to justify disciplinary proceedings.

We found that the officers had a case to answer for misconduct with regards to failing to put safeguarding measures in place or request further information about the man. One officer also had a case to answer for misconduct for making derogatory comments about the man and dismissing his disclosure of self-harm and suicidal thoughts. We shared our report with the force, who agreed. We decided that disciplinary proceedings should be brought against the officers and that they should take the form of a misconduct meeting.

The misconduct meeting concluded in January 2024. The officers were found to have breached the police standards of professional behaviour for duties and responsibilities. One officer also breached the standards for authority, respect and courtesy. These amounted to a finding of misconduct. One officer was given a final written warning, and the other a written warning.

The inquest into the man’s death also concluded that the officers may have contributed to the man’s death by leaving him alone that night. The officers should have identified that he was at high-risk of suicide and explored other measures.

We carefully considered whether there were any learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and prevent a recurrence of similar incidents.

We did not identify any organisational learning in this case.