PCSOs conduct examined after vulnerable man dies – Wiltshire Police, June 2024

Two Police Community Support Officers (PCSOs) on duty in a town centre were approached by a member of the public expressing concern about the welfare of a man who was homeless. The PCSOs were familiar with the man and had encountered him on previous occasions due to his mental health and substance abuse. One of the PCSOs told the concerned person to call an ambulance if they were worried.

The PCSOs approached the man and crouched down to engage with him. One of the PCSOs tapped the man on the shoulder three times in quick succession but received no response. They could hear the man snoring so decided to leave. CCTV footage showed this encounter lasted 25 seconds.

The PCSOs entered a shop, where they spoke to a member of staff and a young couple. They told them that they had checked on the man’s welfare and he was asleep, advising them to call an ambulance if they were concerned. The PCSOs returned to the man briefly, before returning to their police station.

Later that same evening, a member of the public called 999 to report the man was unwell. A woman and the caller had passed the man and were concerned for his welfare. They tried to rouse him but received no response. The woman began CPR while her friend made the emergency call. Two police officers and paramedics arrived and gave the man life support for 38 minutes, but sadly he died.

We received a death or serious injury referral from the force and decided to independently investigate Wiltshire Police’s contact with the man before he died, including the actions and decisions of the PCSOs and police officers and whether these were in line with relevant legislation, national and local policies, guidance and training.

Our investigators interviewed the PCSOs, who answered all the questions we put to them. We also obtained statements from several witnesses. We examined CCTV footage from the area and the PCSOs’ body worn video footage.

We also reviewed information held on the Police National Computer about the man which revealed a history of police contact dating back to 1999. He also had warning markers related to mental health and drug and alcohol use.

We reviewed local and national policies relevant to safe and well checks.

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

We found that the PCSOs had a case to answer for misconduct with regards to failing to conduct adequate checks on the man. We shared our report with the force, who agreed. We decided that disciplinary proceedings should be brought against them and that they should take the form of a misconduct meeting.

We found that both PCSOs had a duty of care which was not properly fulfilled by either of their checks on him. Greater efforts could have been made to rouse the man and establish his condition. The PCSOs did not consider the man’s potential vulnerability as a person who was homeless and on the street with potential addiction problems. The PCSOs should have factored this into their decision making when assessing him and the actions they took.

The misconduct meeting concluded in May 2025. Neither PCSO was found to have breached the police standards of professional behaviour, and there was no case to answer for the allegation that they had failed to adequately check on the man’s welfare.

It was found that there was no evidence of a causal link between the lack of checks made by the PCSOs and the subsequent death of the man, and the man was not visibly in medical difficulty or requiring an ambulance.

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. However, during the misconduct meeting it was stated that it is common for PCSOs and officers to encounter people who were homeless and that there was no specific policy about rousal checks.

Wiltshire Police have been asked to review this and consider learning/policy changes for force-wide consideration. First aid training should also be delivered to staff and reviewed, including the length and detail of training on agonal breathing. Agonal breathing is an abnormal, involuntary pattern of breathing that is a critical sign of a severe medical emergency.