John Henry WHITE · Prevention of Future Deaths report

On 5 November 2019 I commenced an investigation into the death of John Henry WHITE. The investigation concluded at the end of the inquest on 20/10/2022.

The conclusion of the Jury was: -

We as a jury have come to the conclusion of suicide, to which a failure to release the ligature sooner possibly contributed to chances of survival.

The medical Cause of Death was found to be:-

1a Hypoxic Brain Injury

1b Hanging

1c

II

These were recorded as:-

On the 20th October 2019, John Henry White suspended himself ████████
████████ Police were in attendance. John was eventually released and transferred to the Royal Glamorgan Hospital where he died on 23rd October 2019.

The Inquest focused upon: -

A. How, and in what circumstances Mr White came about his death

B. The unavailability of issued equipment (primarily ligature cutters) to the response officers attending upon Mr White leading to an extended period of suspension by ligature.

The jury found that this omission to act to cut the ligature had possibly contributed to his death.

1. In June 2020 the Independent Office for Police Complaints recommended that all response vehicles be equipped with a ligature cutter or similar.

That recommendation was accepted by Chief Superintendent Clare Evans on behalf of South Wales Police in July 2020.

I received evidence from Chief Inspector ████████ that in 2020 South Wales Police had determined to widen the scope of the recommendation to all frontline officers. She informed me that ligature cutters were delivered to the force in July 2022.

As at the 4th of October 2022, approximately 25% of those had been distributed to frontline officers.

She was unable to assist the court with the timeline for the remaining distribution other than in relation to her own force division - a target date of the 22nd of October 2022.

She candidly accepted in her evidence that the incomplete distribution to all frontline officers at this time meant that the scenario faced by the response officers attending upon Mr White on the 20th of October 2019 was still patent & the opportunity to release a suspended individual currently dependent upon whether there had been distribution to the tasked response officers.

That is the concern that I have and wish you to consider and address.

2. A collateral concern, not directly causative of Mr White’s death, arose during the inquest and which I also wish to bring to your attention.

This concerns the availability of bespoke training to response officers in relation to handling similar situations faced by the officers on the 20th of October 2019.

The three attending officers on 20.10.19 indicated that they had not received specific training (notwithstanding the evidence I received from retired Detective Chief inspector ████████ that he had prepared a video for officers covering this type of scenario as part of mental health awareness training in 2017) to assist them in managing the scenario they faced.

Retired Detective Chief Inspector ████████ indicated that he had delivered training that year to officers within the force for the purposes of cascading the same widely.

Given both the statistical and anecdotally evidenced increase in mental health crisis incidents (on occasions resulting in death) that your officers are required to attend, I believe that it would be of benefit to those officers who have not received this bespoke training, (as well, perhaps those who may benefit from refreshing their knowledge) for consideration to be given to retaining the same and expediting its delivery widely – i.e. to all frontline staff.

I would stress that the two immediate response officers cannot be, nor indeed were, criticised in their individual interactions with Mr White on the 20th October 2019. Indeed, and without the apparent benefit of the training, they interacted with Mr White in accordance with the approach advocated by retired Detective Chief Inspector ████████.