Woman suffers fatal burns after contacting police – West Yorkshire Police, February 2019

At 12.18pm on 10 February 2019, a staff nurse at a West Yorkshire hospital telephoned West Yorkshire Police (WYP) and requested a welfare check on a woman who was a voluntary patient and had not returned to the hospital after collecting some belongings from home. The WYP mental health liaison team were spoken with at 4.58pm. The liaison team advised WYP control room personnel that hospital staff needed to clarify if they were concerned that the woman had come to harm otherwise the police had limited powers. The hospital staff confirmed that although there was no reply when they had visited the woman’s home, they were not concerned the woman had come to immediate harm and were happy to continue their own enquiries. Due to this, the police incident log shows police would not attend.

At 6.39pm, the woman telephoned WYP stating her boyfriend was missing, and that he had been missing for ‘about ten million years’. The WYP call handler told the woman he would pass on the call details and try to get help for her. At 6.42pm, the woman again telephoned WYP stating that she had drunk a bottle of turpentine. She again mentioned her boyfriend was missing. The WYP call handler asked for her postcode and when the woman failed to respond, the call handler terminated the call.

At 6.44pm, the woman telephoned WYP for the third time and requested the fire brigade, stating she set herself on fire with turpentine. She mentioned she could not see as she had smoke in her eyes. The call handler asked the woman to put the fire out and the woman responded saying the fire was on a piece of paper from her lighter and laughed. The woman then said she had set her hair on fire. The call handler requested further details and when the woman did not respond, terminated the call.  

At 7.03pm, the woman’s neighbour telephoned the emergency services, reporting the woman’s property was on fire. West Yorkshire Fire and Rescue Service and WYP officers attended and discovered the woman behind her front door; she had sustained significant burns to the top half of her body. She was pronounced dead at the scene. 

During the investigation, we identified an initial indication of alleged misconduct on the part of a member of police staff with regard to how they had dealt with the woman’s telephone call. We subsequently interviewed them and obtained their rationale for their decisions and actions. We also recorded witness statements from control room staff. We obtained audio recordings of the telephone calls made to WYP and documentary evidence from police computer systems. We considered all of this alongside relevant local and national policy and guidance

Our investigation concluded there was no indication police staff may have behaved in a manner that would justify the bringing of disciplinary proceedings or committed a criminal offence or acted in a way which may have caused the woman’s death. We suggested that the member of police staff would benefit from receiving management action in respect of several performance issues.

We completed our investigation in January 2020 and shared our report with WYP who agreed with our findings. We waited for all associated proceedings to conclude before publishing our findings. The woman’s inquest took place in November 2021 and determined a narrative conclusion criticising her discharge from the mental health unit.

During our investigation we identified several areas of potential learning for WYP in respect of contact with other emergency services, the creation of new incident logs when dealing with additional calls from the same individual, the grading of calls and continuous risk assessments.