Police too late to save fourth suicide victim

Police said new procedures had been adopted in the wake of the reports.
Police said new procedures had been adopted in the wake of the reports.
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POLICE in Edinburgh insist lessons have been learned after being blasted for “repeated failures” over the suicide of a vulnerable man – the fourth damning report of its kind in the last three months.

The latest critical report revealed it took police six days to check inside the missing 37-year-old man’s home. When they eventually did force entry, he was found to have taken his own life.

Three similar cases in Edinburgh involving vulnerable people have already seen Police Scotland heavily criticised, which politicians said put 
public confidence in the police at risk.

Today, there were assurances the latest report was the “fourth and final” of its kind with police vowing action had been taken to prevent a repeat.

The man in the latest incident had been reported missing by staff at the Royal Edinburgh Hospital in September last year after failing to return from a home visit.

Despite his mother raising repeated concerns about his wellbeing with the police, he was initially treated as “low risk” and it was not until the following weekend that his body was discovered.

In his report, the Police Investigations and Review Commissioner, Professor John McNeill, identified a number of failings and ordered the actions of all officers involved in the inquiry to be reviewed, adding that the force showed a “lack of clear ownership and accountability” over the search.

Councillor Mike Bridgman, a local board member for Police Scotland, said today he had received assurances from police chiefs in the Capital that changes had already been made. He said: “The police have taken on board the reports and put in place procedures to prevent similar tragedies in the future. We have to commend the police for trying to learn from these very serious mistakes.

“I believe this is the fourth and final report into cases of this kind, and we have to hope the new procedures will 
prevent any repeat.”

In his report yesterday, Prof McNeill said the patient, who had mental health problems and a history of self-harming, was reported missing by the hospital on Sunday, September 8, having been on a weekend visit to his mother’s home.

After the man’s body was found the following Saturday, the date and time of death could not be determined, although it was clear the had been dead for some time.

Failings identified in Prof McNeill’s report included supervisors failing to undertake “critical examination” of all the available information and evidence. The man had been initially assessed as a “low risk” missing person, meaning he was no harm to the public or himself, and limited efforts were made to try to trace him.

Following a review several days into the inquiry, the risk was raised to “medium”, meaning he could be a danger to himself. Despite this upgrade, none of the supervisors considered the level of risk to justify forcing entry to his home.

The investigation found the officers had followed “outdated protocols” on missing persons cases from the previous Lothian and Borders force, rather than the new guidelines from Police Scotland, which came into being on April 1 last year. As a result, officers did not undertake thorough inquiries following the initial report.

Prof McNeill recommended that officers in Edinburgh receive extra training in the management and conduct of missing person investigations.

In addition, he called for the protocol followed in this case to be brought into line with national missing person procedures.

Prof McNeill said: “In this case there were repeated failures to update the Police National Computer with appropriate warning signals, which would have informed the missing person inquiry.

“This case highlights the importance of accurately recording all available information on missing persons and making that information available to operational officers.

“I hope that the recommendations I have made will contribute to improvements in the police response and management of all vulnerable missing person inquiries.”

Tory chief whip John Lamont today said he hoped that lessons had been learned. He said: “It is very worrying that such a seemingly obvious step – to look in the person’s home – took so long to happen. These are stinging criticisms, and I hope the force comes good on its pledge to improve.

“It’s important that the public can have faith in Police Scotland and the priorities it chooses to pursue.”

Jim Eadie, SNP MSP for Edinburgh Southern, who has the Royal Edinburgh Hospital in his constituency, said: “Cases of suicide are devastating for families of those people affected. What is vital now is that Police Scotland learn the lessons in order to prevent cases like this from happening in future and so that other families do not have to go through a heart-breaking situation such as this.”

Mike Crockart, Lib Dem MP for Edinburgh West, and a former police officer, said: “This unfortunately brings to the fore the need for society to better understand mental health issues but especially those who are on the front line.

“My immediate feeling on this case was sadness for the family but then worry about whether this has been a poor reaction from individual officers or whether it’s indicative of poor training and a lack of awareness of mental health issues among the police.”

Assistant Chief Constable Wayne Mawson, lead officer for missing person policy at Police Scotland, said the force was “closely examining” the findings in yesterday’s report. He said: “Since the launch of Police Scotland in April 2013 we have worked to ensure that missing persons investigations are conducted professionally and consistently across the country. We have introduced into every division a missing person co-ordinator.

“We have also created a national oversight group led by a detective superintendent. This group scrutinises ongoing high-risk cases to ensure every opportunity is taken to trace those reported missing to us.

“We recognise that from the moment someone is reported missing to us, our response has to be the best to maximise the chances of tracing that person.

“We recognise that in this case the standards normally being expected of the police have not been met.

“We will look carefully at the findings presented here and continue to modernise our approach to missing persons investigations to ensure we continue to keep people safe.”

ACC Mawson added that police in Scotland dealt with more than 32,000 missing person investigations last year, with each “unique in terms of its complexity and circumstances” while those reported missing “are often vulnerable”.

Edinburgh police commander Chief Superintendent Mark Williams said: “I acknowledge the findings of the commissioner and the recommendations he has made. Since this incident was reported, the division has made several changes to protocols to ensure they align with national procedures.”

Damning verdict on three previous cases

THREE previous cases involving vulnerable people have been the subject of scathing reports since October last year.

CASE 1: Barbara robertson

The body of 36-year-old care worker Barbara Robertson was found by a dog walker in Clermiston Woods on June 30.

The tragic story began the previous day when her husband, scaffolder Colin Robertson, called police over concern for her mental health. But officers judged the husband’s call to be “malicious” after interviewing his wife and her 16-year-old son. The couple were estranged at the time.

Mrs Robertson left her home in Wardieburn Street East later that evening.

Police recovered a suicide note at Mrs Robertson’s home before her body was discovered.

Officers allegedly told their line manager the note contained nothing obvious about suicidal tendencies, and claimed it could have been fabricated.

This judgement, and a failure to recover other critical information such as her mobile phone records, meant the missing person inquiry was not immediately given a “high priority” grading.

The report compiled by Prof McNeill found medical assistance should have been sought for Mrs Robertson after officers interviewed her on June 29.

His recommendations included treating all calls and reports of people with suicidal intentions with due gravity until evidence to the contrary summary is obtained. Prof McNeill also emphasised the importance of carrying out mobile phone-related inquiries at an early stage.

Mrs Robertson’s husband was left devastated by her tragic death and told the Evening News that he hoped the critical report would lead to an overhaul of police procedures.


The man leapt from a flat in Leith on June 12 last year, but survived after landing on a paramedic’s car. Police were lambasted by the police watchdog after it emerged that officers took the man back to his home just hours before he jumped.

Prof McNeill criticised police for failing to log a missing person report when a concerned friend of the man contacted them earlier that day.

Friends of the man had noticed his mental health was deteriorating and reported him missing. When the man was found on the other side of Edinburgh, behaving “strangely”, officers took him home and left him outside the block of flats.

Just before midnight, he plummeted from the seventh floor of Persevere Court.

Neighbours told how he landed on a silver Renault Laguna owned by an ambulance worker and neighbour.

Prof McNeill’s review stated that a friend of the man was asked by police “if he wanted to report him as a missing person and stated he did”. The report added: “No missing person report was raised, the call was recorded as a concern for person and given a grading that did not require an operational police response.

“Full details of the friends’ concerns, including the man’s mental health issues, were not recorded by the member of staff handling the call.”

In his report, Prof McNeill called for a review into how control room staff handled missing person inquiries and said police should “examine the actions of some of its officers and staff”.


The man’s body was found in a friend’s home in Restalrig on March 29 last year.

Three days earlier concerned neighbours had contacted police over fears for his well-being.

Hours before he died, the man dialled 999 asking for police help but despite tracing his mobile phone signal, the control room staff failed to follow through and instead sent officers to his home nearly three miles away.

Later that night, a sergeant realised the missing person and 999 incidents were linked. Officers were tasked with finding the man in the Restalrig area but due to a recording error went to the wrong address. They left a calling card asking the man to contact them but he was found dead at 8.15am that day.

It is understood he may have had a dependency on alcohol.

Prof McNeill said: “The decision by the police not to create a missing person inquiry was a contributing factor to the lack of effective incident response and control. As a result of these failures police senior management were left unsighted on inquiries to trace the man and, therefore, were denied an opportunity for effective direction and control.”

Prof McNeill’s report made a series of recommendations, including immediately re-assessing the way police handle missing person inquiries and addressing failures identified within the control room.