Professor John McNeill has recommended changes to procedures and additional training at E Division of Police Scotland following the death last year.
The 37-year-old man, who suffered from mental ill health and had a history of self-harming, was a patient at the Royal Edinburgh Hospital (REH) and was reported missing by the hospital on Sunday September 8 last year when he did not return from a weekend visit to his mother’s home.
Police did not force entry to his Edinburgh home until six days later, on September 14, after his mother had raised “significant concerns”.
It was clear that the man had been dead for some time, though the date and time of death has not been determined. There were no suspicious circumstances.
The report by Prof McNeill, the Police Investigations & Review Commissioner (PIRC), found that it should have been apparent that the man was a vulnerable person and the inquiry should have been graded as higher risk rather than low risk as it was.
His report said that Police Scotland should have forced entry to the man’s home on September 10 after his mother voiced major concerns.
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 as a result of this tragic case will contribute to improvements in the police response and management of all vulnerable missing person enquiries.”
Prof McNeill also highlighted “a lack of clear ownership and accountability” in respect of the missing person inquiry, with numerous police supervisors endorsing what their colleagues had determined without undertaking a critical examination of all the available information and evidence.
The investigation also found that officers had followed the Missing Person Protocol between the REH and the former Lothian and Borders police force joint protocol (‘E’ Division protocol), rather than the Police Scotland missing, wanted & found persons, abscondees and escapees standard operating procedures (SOP).
As a result, officers did not obtain all available and relevant information following the initial missing person report and subsequently did not undertake thorough enquiries as required by the Police Scotland SOP.
They did not search the man’s mother’s address and did not ensure that medical staff searched the appropriate areas of the REH.
Prof McNeill’s recommendations include that Police Scotland should consider providing additional training to appropriate supervisory ranks in E Division in the management and conduct of missing person investigations.
He called for the protocol followed in this case to be brought into line with the national missing person procedures.
He also recommended that whenever people are reported missing from REH police should make a physical visit to the hospital to ensure they obtain all the appropriate background information.