Man died after an attempt to take his own life during a police response – South Wales Police, October 2019
In October 2019, South Wales Police control room received a 999 call from a man stating he was on a railway bridge. He refused to share his exact location and stated he was going to take his own life.
Shortly after, a member of public called 999 to report a man sat on the wrong side of a bridge with a ligature around his neck.
Two police officers arrived at the scene approximately ten minutes later and found the man. Officers requested a negotiator as the man was refusing to return to the correct side of the railings. The man let go of the bridge in the presence of the two officers.
A third officer arrived with a bladed tool to cut the ligature. This caused the man to drop to the ground where officers proceeded to administer CPR. An ambulance attended and conveyed the man to hospital where he died.
The post-mortem concluded cause of death was a result of hypoxic brain damage, caused by hanging.
We reviewed body worn video footage, telephone call recordings and police records regarding the incident. We also obtained witness statements from the officers.
Our investigation concluded in June 2020.
We concluded there was no indication that a person serving with the police may have committed a criminal offence or behaved in a manner justifying the bringing of disciplinary proceedings. We were satisfied our investigation did not raise any performance issues and shared our findings with South Wales Police.
We waited for all associated proceedings to be finalised before publishing our findings. An inquest was held in October 2022 and reached the verdict of suicide - to which a failure to release the ligature sooner possibly contributed to the chance of survival.
We carefully considered whether there were any organisational learning opportunities arising from the investigation. We make learning recommendations to improve policing and public confidence in the police complaints system and to prevent a recurrence of similar incidents.
We identified an area of learning for the force to consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. We issued a learning recommendation to the force in May 2021. SWP accepted our recommendation and committed to issuing personal ligature cutters for all response officers and police community support officers.
We also issued the recommendation nationally.
IOPC reference
Recommendations
The IOPC recommends that South Wales Police should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given to officers in how and when to use such a piece of equipment. The item of equipment will need to be robust enough to cut through a substantial ligature such as a climbing rope, which is what was used in this instance.
This follows a case where a person died after hanging themself from a bridge in the presence of officers who had responded to reports of a person in mental health crisis. Despite the officers being present they were not equipped with any equipment capable of cutting the rope and saving the man's life.
Do you accept the recommendation?
Yes
Accepted action:
IOPC Investigation into DSI:
Thank you for your correspondence dated 23rd June 2020 relating to the above investigation.
As the delegated Appropriate Authority, I have considered the findings of the IOPC independent investigation into this incident and in accordance with Schedule 3 of the Police Reform Act 2002, I am provided my 23(7) response within this letter.
I note that that there is no indication that any person serving with the police has either committed a criminal offence or behaved in a manner which would justify disciplinary proceedings.
I have not been asked to make any determinations in relation to the performance of any person involved but I have been requested to review the final report and Decision Makers Log and comment on the suggested learning recommendation.
The proposed recommendation is that all operational police vehicles should be equipped with some form of implement capable of cutting a ligature of width greater than a few millimetres (i.e. a more robust tool than the keyring ligature cutters). It is also suggested that training should be given to officers in how and when to use such a piece of equipment.
The Lead Investigator highlights that the item of equipment will need to be robust enough to cut through a substantial ligature, such as the climbing rope used in this case.
I have viewed the report submitted by the Lead Investigator highlighting similar equipment used in local Forces which is very helpful.
I support this recommendation and in doing so I have also consulted with my colleagues, a Chief Inspector, Force Lead for Hostage and Crisis Negotiating and the Chief Superintendent, Head of Operations.
The Chief Superintendent has reviewed the costs of the kit used by Gwent Police which he thinks would be our preferred option.
Draper Mini Saw £3.34
Draper Emergency Hammer and Cutter £10.30
Safety Knife (Fish 200) £8.15
Total £21.79
According to fleet, we have in the region of 312 response, RPU vehicles and vans so it would cost around £6798.48 for the Force.
He suggests allowing a small extra amount for additional vehicles so the final costs would be £7000.
There is a cost implication to purchasing the equipment but following its purchase, training on when and how to use this equipment could be incorporated into First Aid Training, so there would be no additional costs incurred.
This relatively small cost would undoubtedly be offset by the benefits and risk mitigation likely to arise from the change.
In order to progress the implementation of this recommendation without undue delay, I have submitted a report to the ACC this week with a view to this being discussed and ratified at DCC Chief Officer Group (COG) this week.
If ratified at DCC COG, the Chief Superintendent will progress this through the Force Uniform and Equipment group.
I have every confidence that this will be ratified and will of course update in due course.
Yours sincerely,
Chief Superintendent
Professional Standards Department
The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given to officers in how and when to use such a piece of equipment. The item of equipment will need to be robust enough to cut through a substantial ligature such as a climbing rope, which is what was used in this instance.
This follows a case where a person died after hanging themself from a bridge in the presence of officers who had responded to reports of a person in mental health crisis. Despite the officers being present they were not equipped with any equipment capable of cutting the rope and saving the man's life.
Do you accept the recommendation?
Yes
Accepted action:
- Letter to Chief Constables to make them aware of this recommendation and for encouragement at a local level for them to provide the outlined equipment where appropriate and in the absence of such capability now.
- Send out a communication including the recommendation on Knowledge HUB.
- Send out a communication to L&D leads for dissemination to staff.
T/Assistant Commissioner for the Metropolitan Police Service/ NPCC Lead for Self Defence, Arrest & Restraint (SDAR)