The Police Investigations and Review Commissioner (PIRC) has found that despite Mr Croal’s mother phoning police three times to report concerns for her son’s safety nothing was done.
Mr Croal’s mother Elizabeth Gillespie made three calls on February 20 last year, but no action was raised and officers were not sent to check on him.
It was not until she phoned for a fourth time on February 22, more than 38 hours after her first calls, that officers were sent to Mr Croal’s home in Fallin, Stirlingshire, and found him dead.
His family have asked if Mr Croal, who died from a gastrointestinal bleed, could have been saved had the police acted earlier.
The PIRC report said there was evidence of an apparent reluctance to transfer calls from Mr Croal’s mother to the correct department, as she had chosen an incorrect call option.
The PIRC investigation also found that there was no guidance available to Police Scotland Service Centre staff on how to deal with “dropped 101 calls” from members of the public.
Mr Croal’s mother first contacted Police Scotland at 1836 hours on Monday 20 February 2017 after she had gone to his house twice that day but received no reply. She expressed her concerns that she was unable to use her key to get in because there was a key on the inside of the lock. She also wanted to know if her son had been taken in to custody.
Mr Croal’s mother was put through to a Custody Sergeant, who confirmed he was not in custody and told her she would need to hang up and phone back on the 101 phone number and speak to a Service Advisor to report her son as missing.
She telephoned again at 1839 hours on the 101 number but selected the wrong phone option and was again told by a police officer to redial 101 and speak to a Service Advisor.
No efforts were made by Police Scotland to transfer these two calls to members of staff who could assist her.
Mr Croal’s mother telephoned for a third time at 1842 hours and got through to a Service Advisor in Police Scotland’s Govan Service Centre and repeated her concerns. She again asked if her son was being held in custody at Randolphfield Police Station in Stirling.
After taking some details, including contact information for Mr Croal’s mother, the Service Advisor checked to see if Barry Croal was in custody.
Mr Croal’s mother interpreted this as meaning that the service adviser would call her back after she had made enquiries and she terminated the call.
The Service Advisor was unable to trace a telephone number for Randolphfield and on returning to the call to update Mr Croal’s mother, found that she had hung up.
The Service Advisor did not call her back on the number which she had provided, instead updated the call log with the words “Advice Given/Resolved”.
Mr Croal’s mother contacted Police Scotland for a fourth time at 0906 hours on Wednesday 22 February 2017 and spoke to another Service Advisor within Govan Service Centre. She explained she had contacted Police Scotland two days previously and had been expecting Police Scotland to call her back about her son.
When this Service Advisor was made aware of the circumstances, she immediately raised an incident and police officers were sent out to Mr Croal’s house at 1000 hours on 22 February 2017.
They forced entry and found his body inside. The attending doctor certified the cause of death as a gastrointestinal bleed, adding that an estimated time of death could not be determined.
PIRC Commissioner Kate Frame said: “Despite Barry Croal’s mother repeated efforts on 20 February 2017, in three calls to Police Scotland, to communicate her concerns about her son’s safety she received little assistance in resolving those concerns until she phoned Police Scotland for a fourth time, two days later.
“In her earlier calls, she made it clear to both police officers and a member of civilian staff that nobody had seen her son for a number of days and that she had been unable to get into his house because it appeared that the door had been locked with keys from the inside.
“Barry Croal’s mother experienced a variety of failures by three separate police personnel within a ten minute period, which must have undoubtedly been very frustrating and ultimately a distressing experience for her.
She added: “This episode provides the opportunity for further learning and improvement by Police Scotland, to ensure that staff act appropriately and provide the correct level of service to members of the public seeking their assistance.”
Mr Croal’s family released a statement saying: ““Barry was a father, son, partner and brother who is sorely missed. It has been just over a year since his death and the circumstances surrounding it have made it difficult for us, as a family, to come to terms with.
“We are aware of the PIRC report and the findings contained within it and we hope that Police Scotland take note of these findings so that no other family has to experience something similar
“We are thankful of the support we have received but would now ask for privacy as we continue to come to terms with the loss of Barry.”