Is a decision correct because of the quality of the decision-making, regardless of the outcome OR because of the quality of the outcome?!
- In the risk prediction business that professionals in policing, mental health and emergency medicine (inc paramedicine) find themselves, it’s quite possible you could make an entirely correct, completely defensible decision which takes account of all relevant law, statutory and non-statutory guidance and local policy, only to find you still have to explain yourself to an inquest, investigation or inquiry because of an adverse outcome.
- Not everything is predictable and preventable, as I would hope should be obvious and agreed by all.
- Equally, you could find professionals take decisions which don’t really stand up to reasoned scrutiny, because of short-comings against those legal, guidance and policy frameworks, only for the outcomes to be exactly that we might hope they would be on a good day at work.
- But not everything which goes well, is because of the decision-making by professionals.
It’s the fourth College of Policing “risk principle” that –
“Harm can never be totally prevented. Risk decisions should, therefore, be judged by the quality of the decision making, not by the outcome. It is in the nature of risk taking that harm, including serious harm, will sometimes occur.
- The task of identifying, assessing and managing risk is challenging, yet many people judge risk decisions simply by examining the end result, that is, whether the decisions led to success or failure, to benefits or harm. The law, however, recognises that harm will sometimes occur irrespective of the quality of the decision making, and does not require that all risks are eliminated.
- The fact that a good risk decision sometimes has a poor outcome does not mean the decision was wrong.
- Similarly, it cannot be assumed that a decision was right just because no harm occurred.
This is an edited version of principle four and puts in to formal guidance what I’m getting here but the point I want to make about this is different.
MISCONDUCT
We learned a few months ago a police inspector was given a written warning for misconduct after risk assessment of a s2 MHA patient. Following a report to the police which almost certainly should have been treated as a high risk missing person, where there was an “immediate risk to life”, it was graded as medium risk which makes it likely there was less urgency, fewer resources and fewer tactics available to trace the young man who went missing. Tragically, despite someone else upgrading the matter to high-risk the following morning, he was able to access a railway line before being found and died.
An obvious example of risk assessment gone awry and where formal proceedings resulted for a failure of risk assessment.
So my question is this: if (wilful) failures in risk assessment are disciplinary matters, where are the similar proceedings for those whose failure in risk assessment led to no adverse outcome? – remember: “it cannot be assumed that a decision was right just because no harm occurred.” It was a regular thing in my operational service that inspectors starting duty reflected on risk assessment decisions for missing people and upgraded them because they weren’t satisfied with the previous assessment by the initial inspector; OR the missing persons team often upgraded medium risk missing persons investigations to high because they weren’t satisfied.
RCRP … AGAIN.
Sorry to bang on about this … actually, I’m not sorry: it’s important.
We are now at the point where we have eighteen inquests for people who died where RCRP is cited or relevant; sixteen of which led to Preventing Future Death reports, fifteen of which ended up telling us important things we should think about. But we only get a PFD if someone dies and even then, not always. Two “RCRP inquests” did not lead to PFDs and I have to admit, I would have thought they were as necessary as the others and could have been helpful about issues like training. More on that another time.
What about the cases of RCRP decision-making where no-one dies, which is obviously the vast, vast majority of cases? We don’t really know much about this because RCRP has not been formally and properly evaluated by reputable researchers. Indeed I’m told by more than one reliable source free academic evaluation was offered and declined, which doesn’t make sense to me, if true. But how many times would we learn of 999 calls to the police for matters which should see a police deployment and which doesn’t get one, but where no-one dies or suffers serious harm?
We just don’t know – but what we do know is those non-police professionals who gave views to the University of York study (2024) on the introduction of RCRP talked about decisions they couldn’t get behind. I also know I saw incident logs in the final year of my career where I wondered how on earth someone could think a non-police deployment was the correct response. I’ll forever remember the example of the man who claimed to have taken an overdose of two drugs in quantities which made paramedics say “if he has taken what he says he’s taken, he’s in a lot of trouble.” He left ED before blood tests were done and yet the police wouldn’t deploy, even after the NHS stressed “he could collapse and die”. Still an ambulance job, apparently – despite no-one knowing where he’d gone.
THREE BECOME ONE
The police (and other agencies) deal with complicated, sensitive and time-critical business, which sometimes has to be done amidst a degree of confusion or uncertainty, with incomplete information, finite resources and whilst juggling goodness knows how many other serious matters at the same time – something which is rarely mentioned when a specific failure is being deconstructed and analysed. That doesn’t excuse failures, but it will contextualise some of them. Whilst most officers would agree, there has to be accountability when things go awry, the thing which is never discussed is how the failure to hold people accountable for poor decisions which don’t go awry creates cultural conditions in which which future decisions are taken.
When I started as an officer and when I first started to “act up” as an inspector, there would be NINE inspectors on duty for Birmingham, covering the responsibilities which at the time the incident went awry were being covered by THREE inspectors – and it’s not even as simple as saying it’s “like doing three jobs” because as well as the organisational reform which reduced cover at that level of command, the population rose, demand went up, overall officer numbers fell, and IT was introduced which meant it took officers longer to do everything – all of which impact the responsibility carried by inspectors to deliver operational policing to a major city, as they are the tactical leaders in the police, 24/7.
When I was young and daft, I once found myself covering three police areas because of an inspector shortage due to short-notice events. I got to work to be told the neighbouring area’s inspector had been called to court and I’d be covering two areas – it happens, had done it before; fine. Then another inspector rang me just after midnight to say they had to go home because of violent illness which struck them as they were starting work. Nothing went wrong during the six remaining hours of my shift but a few days later I found myself in the superintendents’ office for a chat which didn’t involve coffee where it was made clear me taking on a third area was “absorbing risk beyond common sense” and I should have made sure another inspector still covering just one area, took on the third so we had two each. And know what? – entirely fair comment. It made sense, I just had to admit in my determination to show I was could take care of business at the rank I aspired to attain, I hadn’t thought of it and had just cracked on and managed it.
Some Chief Constable subsequently reorganised the force internal boundaries and made Birmingham two police areas for response policing purposes (albeit without responsibility for custody blocks, which had its own inspector). So it’s force policy to have just one inspector covering what was previously three jobs despite my having been told off for doing exactly that for just six hours on a quiet weekday several years before. I’ve often wondered whether that superintendent put his hand up at the force level management meetings to tell the new Chief Constable how his restructure was “spreading risk beyond all common sense” or something similar, but either way, is it any wonder we end up spending some time looking at why balls got dropped by looking only at the one which fell and forgetting there were four or five others in the air at the same time?
Awarded the President’s Medal, by the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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