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Hertfordshire's police have been criticised for their response to the case of a missing man later found dead at Watford General Hospital.
An inquest's heard 22 year old Jason Hearn took his own life in a bathroom at Watford General in May 2009 when the balance of his mind was disturbed.
An investigation by the police watchdog's found the police response to reports he'd gone missing were "disjointed and disorganised" with no single officer taking ownership of the search for Mr Hearn.
The Independent Police Complaints Commission say "police officers collectively failed to listen to the pleas of an increasingly desperate family, who made 16 calls to police over a four day period. As a result of the IPCC investigation, two Hertfordshire officers attended a formal misconduct meeting and received management advice. A further 14 police officers have received management action by the force."
Jason Hearn was taken into Watford General Hospital after collapsing at home on Saturday 2 May 2009. He left the hospital at lunchtime against clinical advice and Hertfordshire police were notified. Shortly after he was found by police, and returned to the hospital where he remained voluntarily. He reportedly left the hospital again later that evening and Hertfordshire Police were informed. On Wednesday 6 May 2009 his body was discovered by a member of staff in a shower room at the hospital. A police investigation concluded there were no suspicious circumstances.
IPCC Commissioner Rachel Cerfontyne said: "His family recognised Mr Hearn’s actions were alarmingly out of character and repeatedly told a succession of officers – they were offered reassurance but little else. Their pleas for help were met with a woefully inadequate response from Hertfordshire Police. There was a collective failure to recognise the risk to Mr Hearn and listen to the very people who knew him best, his family.”
"Enquiries made were piecemeal and repetitive and on occasions results weren’t recorded anywhere to assist other officers. A more proactive investigation may not have affected the outcome but may have led to the discovery of Mr Hearn sooner, saving his family a period of unimaginable stress and anxiety.”
The investigation found that police officers discovered Mr Hearn quickly after he walked out of A&E on the Saturday he was admitted. Police appropriately detained him under Section 136 of the Mental Health Act, but on returning him to A&E no officer gave clear communication to hospital staff that they had done so. Such detention should trigger an assessment by an approved social worker and psychiatrist, but no assessment was requested of the NHS staff. There was a lack of communication at this time from police officers to the healthcare staff involved in co-ordinating Mr Hearn’s care.
IPCC Commissioner Rachel Cerfontyne said: "It is impossible to say if better communication between the police and health professionals would have altered the eventual outcome, but clearly this lack of co-ordination over Mr Hearn’s welfare was unsatisfactory."
Hertfordshire Police say they've now made changes in the wake of what happened. In a statement, they say: "Our sympathies lie with Jason Hearn’s family and we hope that the completion of this week’s inquest has helped them come to terms with Jason’s tragic death.
"Although Hertfordshire Constabulary officers found Jason and returned him to hospital on the first report of him leaving Accident and Emergency, our response to the second report of him going missing could have better.
"As well as immediately referring the conduct of the missing person enquiry to the Independent Police Complaints Commission (IPCC), the Constabulary initiated its own internal investigation to identify any improvements. A total of eight recommendations have been made and have already been implemented or initiated."