Coroner issues Prevention of Future Death report to West Midlands Police over flawed emergency call system

HM Senior Coroner for Worcestershire has sent a Prevention of Future Death report to the Chief Constable of West Midlands after the conclusion of the inquest into the death of Jason Devoti ; Jason died on 9th October 2018. The Coroner in a ruling dated 10th January 2020 noted that “in the course of the evidence, it was apparent (and properly accepted by Chief Inspector Sidhu on behalf of West Midlands Police)’ that the Force had failed to deal with a request to undertake a welfare check on Mr Devoti as they should have, and that there were many other requests for Police assistance which were similarly not being dealt with in accordance with the risk assessments being undertaken.”

On Sunday 7th October 2018 the family of Jason Devoti reported him missing to police and raised concerns about his welfare after not hearing from him following his discharge from hospital in Redditch, Worcestershire. Jason had been admitted after an overdose.

West Mercia Police located the address Jason had been discharged to and on Monday 8th October 2018 at 12.35pm they asked West Midlands Police to conduct a welfare check; the accommodation was in Birmingham. This request was risk assessed by a West Midlands Police call handler at 1.04pm as requiring a ‘P2 priority response’, i.e Officers should arrive on scene ‘as soon as possible and within 60 minutes of receiving the call’.

West Midlands Police opened a log on their system, in the same way as they would with calls that came to them via 999 and 101, and the request was sent over to their Resource Allocation Dispatchers so that Officers could be allocated to attend. The log was accepted at 1.31pm by a Resource Allocation Dispatcher who shortly afterwards went on her break. Thereafter no action was taken in response to the log until 6.18am on Tuesday 9th October 2018, almost 18 hours after the request was received, when a note was made that the task was ‘for allocation when resourcing allows’. At no stage was the matter escalated to a supervisor as it should have been once the 60 minutes to attend had elapsed.

On Tuesday 9th October 2018 at 11.40am an Officer from West Mercia Police attended the address where it was suspected that Jason was. He was found dead. Jason’s cause of death was acute ethyl alcohol poisoning. Investigations have not been able to determine with any certainty when Jason died, he had last been seen alive by another resident of the property during the morning of Sunday 7th October 2018, however the Pathologist gave evidence during the course of the inquest that it was possible Jason was still alive when West Midlands Police Officers should have attended to check on him.

Evidence was given during the course of Jason’s inquest by four Resource Allocation Dispatchers who described overwhelming levels of work and problems in allocating Officers to attend incidents, such that frequently Officers did not attend P2 incident within an hour and often not within 6 hours when an overdue message would appear on their system. They would regularly start their shift with a large number of logs outstanding (150-200) and they would also have to deal with frequent incoming logs. A Chief Inspector gave evidence that there was an escalation policy in place at the time whereby P2 logs which were approaching 40 minutes since the call without an officer being allocated should be escalated to a Supervisor. The evidence of the Dispatchers however was either that they were unaware of the escalation policy at that time or that there was little point in escalating matters to supervisors who would tell them there was nothing that could be done. One dispatcher noted ‘the crux is that we don’t have enough police officers on the streets to deal with incidents’.

HM Senior Coroner for Worcestershire in his ruling explained he was ‘concerned at how overwhelmed those working in the Bourneville control room had been by the increased demand on resources, and how their views about any improvement in the situation in the months following did not appear to match what I was told by’ those managing them.

He further explained ‘Whilst I understand that the West Midlands force is undergoing a period of transition so far as their control rooms are concerned, I am not satisfied that measures have yet been put in place to ensure that all those working in control rooms have received sufficient and appropriate training to deal with situations of increased demand……I therefore remain concerned that in times of increased demand, and particularly unanticipated demand, there is a risk that West Midlands Police will be unable to resource and attend a P2 incident within the 60 minute period that is their stated aim, and that that in turn will create a risk of death of the subject of such a P2 incident, if vulnerable and at some risk of harm as Mr Devoti undoubtedly was.’

Jason’s family who attended his inquest, said;

‘Jason was a good brother, a loving son and later a devoted husband, father and uncle. He was kind, caring and calm with a gentle and warm demeanor, making him liked by everybody he met. Despite his successes and usual zest for life, Jase experienced a number of difficulties with his mental health which him to self-medicate with alcohol. His death has devastated his family and friends, who fought tirelessly for the final two years of his life to keep him safe, happy and alive. It has been a source of significant distress to us that as a result of the failings of West Midlands Police we will never know if they could have saved Jason’s life. Other concerns we have about Jason being discharged from hospital 3 days prior to his death, and being placed in temporary accommodation far away from his family were not explored during the course of his inquest’.

Clair Hilder, representing the family, said;

‘Jason’s death provides a stark example of the reality of the cuts to resources which Police forces across the country have faced. The evidence given during the course of the inquest was shocking in terms of the number of cases where Officers were not attending within the timescales they were supposed to be, rendering the grading and risk assessment process almost obsolete.’

Jason’s family are represented by Clair Hilder of Deighton Pierce Glynn and Taimour Lay of Garden Court Chambers and have been assisted by INQUEST.

Jason’s Inquest took place between 6th and 10th January 2020 at Stouport Coroner’s Court. The Coroner’s Prevention of Future Death report sent to West Midlands Police is dated 21st January 2020; the Force is due to provide a response by 13th March 2020.