Sunday, 28 February 2010

Near Misses - But No Organisational Learning

Risk assessments - are they just a way of apportioning blame when it goes belly up? I'm hearing a lot of talk from senior management about doing a dynamic risk assessment before attending calls, this is all since single patrol has been imposed. It would appear I must even record in detail my rationale if I deviate from this diktak taking into account the risks to be managed.

I've seen the ambulance service is also stricken down by this mindset. I'm aware of three calls the other day where the ambulance control called us because a risk assessment showed they shouldn't attend without police. I'm not talking about high level risks surrounding firearms but perceived low level violence. We will if we have a unit always support our first responder colleagues, but I've noticed they won't even approach the address until we get there.

Already one such call turned into what we call a critical incident because the casualty was at risk of death. If he had died, because there had been police contact a major investigation would have been launched putting every single police officer under scrutiny. It was touch and go at one stage meaning every constable had to justify what he did and why. I had an overview input after he reached hospital and without going in to details could see that, we the police would have got slaughtered had the casualty popped his clogs. A very near miss and suffice to say the single patrol policy and other decisions made by those enjoying their week-end off played a part. I could almost hear the inquest narrative highlighting systemic organisational failings and our retort of being very sorry and promising to learn from our mistakes.

The facts were evident and a number of circumstances conspired together contributing to what would have been the death of an individual. No police officers did anything wrong but the spotlight would have been on them when the blame actually lay elsewhere, around saving money and resources.

I did a report highlighting the issues and somebody higher up will read it and breath a sigh of relief. Will we learn from it as an organisation? I doubt it - but I had all of my team in to discuss things in depth. They are in no doubt they are the ones who would have been left out on a limb and criticised when actually they assisted in saving a life. It will go into their experience banks and some of them with 30 years to go will benefit from it. I'll keep the report to produce when something similar happens and somebody tries to point the finger - stating risk assessments.

Death following police contact includes non crime stuff - like us trying to save life too.

20 comments:

Metcountymounty said...

Now wouldn't it be tragic if that report found itself on the desk of the editor of The Sun.

Stressed Out Cop said...

I think more impact if I produced it at an inquest ...

Dandelion said...

Am I correct in guessing that if the person had died, it would in reality have been the ambulance's fault for refusing to attend a potentially dying person because of over-estimating the risk to themselves?

Impact is all very well, SoC, but it sounds like you're happy to wait till someone dies before producing your report...doesn't that undermine your argument a little bit?

Blue Eyes said...

Someone told me that if someone dies within 24 hours of having any contact with the police at all it is considered a police-related death and has to be investigated as such. Is that right?

Stressed Out Cop said...

Dandelion

Don't know about the ambo's - they have to risk assess for their own safety - and their control do that having taken the call. As soon as we are hands on - we are in the frame too.

The report is produced internally and if there is any learning it should be acted upon. At the moment nobody seems to listen to the front line .. hence my lack of confidence. I may be wrong !!! but I doubt it - don't forget the blame is easier to offload at the bottom.

Plenty of paperwork without a death .. so no I'm not waiting for another one to happen. I'm just looking after my people.

Stressed Out Cop said...

Blue

48 hrs I believe

Metcountymounty said...

If the ambulance crew had refused to go in without a Police escort because it was unsafe, and no Police escort was available because the team was under resourced then it would be the Police who got the blame. Always have been, always will be.

Dandelion said...

I thought you were supposed to look after the public?

If there's a conflict of interests, isn't that a sign that something is very wrong?

MCM, why aren't the ambulance held responsible if it's their fault?

Metcountymounty said...

Dandelion, frontline officers have been saying for years that something is very very wrong, and for years the public have been telling us to 'stop whinging and get on with it' when we voice concerns through the right channels.

As for it being our fault if we are involved or are supposed to be involved and it goes wrong? We are the senior emergency service who's job it is to protect the public and the other services so if we can't do that for any reason - no matter how reasonable - then it's our fault as it's our responsibility. If a situation is too dangerous or presents an unacceptable risk to paramedics or firefighters (such as public order or a violent group/individual) then they hold off until we can make it safer. If someone dies in that situation then ultimately it's down to us, as wrong as that may seem sometimes.

Dandelion said...

Well, I think that's ridiculous. If someone dies because the ambulance's risk assessment is on a hair-trigger then that's clearly the ambulance service's fault.

As a MoP I'm not aware of the police ever admitting or complaining that something is very very wrong. I'm aware of complaints over pay, but that's it. Wouldn't it be great if we could join forces, the public and the good police? Could we move mountains, d'you think?

Stressed Out Cop said...

Dandelion/MCM

Health and safety above all else and if you do the right thing you're a hero - if it goes wrong and you end up dead - you are still a hero but your supervisor is in the shite for letting you be a dead hero.

Remember the outcry re the PCSO's and the child in the lake. If the PCSO's had attempted a rescue and one of them died too - one of their managers and possibly the police service would have been up for manslaughter.

We don't want this - somehow we've ended up there.

I'm more then happy to see a Royal Commission into Policing and what is not right at present. Don't care about the pay - but I don't want to be lied to be the home office either.

The public is too divided about what they want with minority groups shouting the loudest - if you meant the silent law abiding majority of course I agree - the country would be a better place.

Mermaid of Moorgate said...

I recall one incident where a drunk and obviously mentally ill man was trying to cut himself with a shard of glass. The ambulance professionals - about four of them - were just sitting around waiting for the police to come.

I asked if I could go up to the man and talk to him as a volunteer Mind counsellor. "No, he might cut you".

I could see their logic, but a) he was fat b) drunk c) in no state to be able to catch me, let alone get near enough to cut me as I was several meters away.

I think in that situation, common sense should have prevailed, as the man was slicing his hands up in a cry for help and bleeding everywhere while the ambulance crew waited for the cops to come.

All the cops did was go up to him and take the glass out of his hand, before leading him to the ambulance crew.

In a situation like this, shouldn't there be some special coppers assigned to cover a paramedic's beat?

Or would that be too costly for NuLab?

Stressed Out Cop said...

Mermaid

Welcome - invokes lovely images does your name.

I believe some areas have trialled joint patrols with a lone paramedic on board a police car - as we too make quite a demand on the ambos calling them for drunks / assaults and to the custody suite. Don't know if this will roll out but it still has us in police contact and up for investigation.

We could have never let you near him - in case you got injured and sued us - duty of care to you see.

common sense in 2010 ... Mmmmmm

Metcountymounty said...

Dandelion, Police officers have been trying to tell people for literally decades via the Federation and the media that there are plenty of things wrong with policing. Excessive paperwork, national crime recording standards, CPS, increasing social work etc all lead to situations where someone phones 999 legitimately and we can't go because there is no one left.

We shouldn't spend huge amounts of time having to pander to what some councillor thinks are the local crime problems, or that Wayne and jeanette are threatening each other for the hundreth time by text message, or 4-6 officers sitting in custody for 12 hours with a violent schizophrenic because the local mental health hospital are useless and deathly slow at doing anything.

These are things we have complained about and the usual answer from the public is get on with it and stop complaining. The issue of the pay increase was the lie from the home secretary and her intention to abolish the negotiating board after 30 years with no consultation, the amount of money involver wad irrelevant but as usual it was spun by the media.

We have got to the situation we are in because no one listens to the people on the ground and the senior officers have romantic ivory tower notions of what will work.

The end result is there are now less people able to deal with what occurs quickly - but more importantly effectively - and ultimately people will die. When they do then reports like the near miss that SoC put in are the things that will make the difference, but as long as no one listens to those actually doing the job on the ground nothing will change

MTG said...

Dandelion has yet to realise there is nothing we citizens can tell MCM about UK policing, especially any of the faults which made it so unpopular.

Let us all share the morsel of comfort that our curator of police service history will never be burdened with a commission as Architect of police reformation.

Hogday said...

Most of the experts I encountered always seemed to turn up afterwards, to distribute the blame.

Crime Analyst said...

Hi SOC

I wonder if you can help me? Yesterday morning my mobile rang and I answered it as normal. I was really surprised to hear the caller say “Hello Steve, this is Chris Grayling”

As you probably know, Chris is the potential Home Secretary if the Tories win the election. Contact up to this point had only been by e mail, but the purpose of his call highlighted a pressing need for a bit of help.

Early in January, I sent an FOI request to each of the 43 police forces asking the questions:

1. Please provide the total numbers of officers by rank within your force for 2009
2. How many of those officers were assigned to response duties in 2009
3. What are the non response administerial departments within your force?
4. How many police officers are assigned to each of these departments, by rank?

Inspector Gadget, Copperfield, Bloggs and many others have made frequent reference to the disparity between the resources available for response duties and those assigned to ad ministerial or clerical functions. I wanted to put actual numbers to this problem, to identify the enormity of the issue. I have been pleasantly surprised to receive detailed responses from all but 6 of the 43 forces, accounting for over 120,000 of the 143,000 officers in England & Wales. The results are in and I am sure you won’t be surprised at how dangerously low the response numbers are across the country. (45% across England & Wales, which is an absolute best case scenario, allowing forces the benefit of the doubt when we suspect they have slightly overstated the numbers).

I am in the process of completing the report and it will be available on our site shortly. I copied Chris Grayling in on the progress. Chris telephoned me to ask if the report would be ready today/tomorrow, as he wants to include it in the Times Online week long feature on crime which starts next week. As you can guess, he has a direct link into their office and assures me that the content will go to print.

HOW CAN YOU HELP?

To supplement the report, Chris is very keen to have anonymous input (via us) from frontline officers about the consequences of the response shortages you guys tell us about. I have started trawling the police blog sites looking for relevant articles and comments that will support the statistical report. I have a fair bit of material already, but as you know your own sites best, I hope you might be able to locate particular relevant links from memory. I will NOT be identifying the sites where the articles were sourced to protect the anonymity of the authors (unless you specifically request the URL to be included). I will delete usernames, dates etc unless you advise otherwise As we are all out there in the public domain anyway, I can only envisage increased visits to your sites if you choose to specify the URL, but this is entirely your choice.

Among our initial observations are that the exceptionally low response numbers are further diminished by:-

Splitting the officer count across three shifts
Taking rest days, sickness, annual leave and courses into account
The British Crime Survey section reflects head of population per full time equivalent officer
This is massively different when weighed against purely response numbers
The low response numbers throws serious doubts onto the ability of forces to deliver on projects such as “The Policing Pledge”

I’m sure you can think of plenty of other implications the numbers will affect, so any views or suggestions are welcome.

As soon as I have a draft copy I will copy everyone in.

Hoping you can help.

Kind Regards

Steve

Steve Bennett (ex PC West Mids)

http://thinbluelineuk.blogspot.com
steve.bennett@nice-1.co.uk

Stressed Out Cop said...

Steve

I was just re-reading your comment but then see The Times are involved.

This would be the same Times that outed my blogging friend Nightjack - and now wants to highlight policing issues using bloggers.

I don't want to be associated with The Times in any way - for obvious reasons.

I would suggest Chris Grayling gets his backside down to any police station for a late turn shift and he will see for himself and he'll get told exactly what's going on. He will have to do this before the election is called.

Of course if The Tories hadn't reneged on their referendum promise over Europe, Cameron could have been ordering his curtains for number 10 from The John Lewis list.

Impossible is such a negative word and shows weakness. They lack vision and resolve.

They may get my vote for tactical reasons but then I'm back to UKIP.

I do wish you well with what you are doing - By all mean's use any of my stuff for your report - but I don't want it or my name near The Times.

Have they apologised to Richard yet? Thought not

MTG said...

Steve Bennett (ex PC West Mids) has the ritual knife for career hari kari poised for action, SoC.

I do wish him oodles of support and I raise my glass to Copperfield, Gadget and Co, hoping they get stuck in.

Crime Analyst said...

SOC

Thanks for that, I agree with your sentiments about The Times treatment of Richard, it was treacherous beyond belief.

Thanks for the kind offer to use some of the stuff. I am removing all references to sources, dates, assumed identities etc, focusing morfe on the content which is what seems most important.

Chris Grayling mentioned during the call that he was out visiting forces and as a result of what's gone on these last months, he makes a point of insisting on private time with the front line guys to get to the core of the problem.

He says he accepts he faces a big problem untangling the web of deceit that exists with some Chhiefs and SMT's, but realises the importance of the frontline viewpoint. We'll have to see what he does if he gets the opportunity.

The report contains some shocking stats already, so hopefully it may achieve something positive.

Thanks again and all the best

Steve