Eight police officers disciplined over failures after man goes missing from hospital

Published Date: 01.09.2014

A Police Ombudsman investigation has resulted in eight police officers – two Inspectors, three Sergeants, and three Constables – being disciplined for their failures in the search for a man who had been reported missing and who was later struck and killed by a train.

PDF: Full Public Statement

Twenty nine year old Jonathan Magee was killed when he walked in front of a train at Knockmore Bridge near Lisburn on Saturday, 29 January 2011.

Jonathan MageeJonathan Magee

The Police Ombudsman, Dr Michael Maguire, said the police response to Jonathan’s disappearance was inadequate, lacked communication between the officers involved and largely ignored the procedures in place for such issues.

“Although they were told Jonathan was at ‘high risk and suicidal,’ it took police almost 7 hours to formally make this assessment themselves and then having done so, they largely ignored it.

Minimal inquiries were conducted into Jonathan’s whereabouts in the last few hours of his life.

Minimal inquiries were conducted into Jonathan’s whereabouts in the last few hours of his life. A number of opportunities to find him and return him to the hospital were missed,” said Dr Maguire.

Jonathan Magee had a history of mental illness and in the week prior to his death, the police had on one occasion initiated a search for him after his family had said they were concerned for his safety. On another occasion police found him and took him to Whiteabbey Hospital. Later that same day, he had been taken to Lagan Valley Hospital and then transferred to the Mater Hospital, where he later discharged himself.

On the morning of Friday, 28 January, the day  before his death, Jonathan’s sister phoned the police to say she was concerned for his safety as he was missing, suffered from depression and had tablets in his possession.  Police then visited his sister, checked at his home and in the immediate area, checked with the Mater, the Lagan Valley, the Royal and the City hospitals and circulated his description.

At 2:28pm, Jonathan phoned the police to say he was in Cavehill Park in Belfast, had taken an overdose and had cut his wrists. 

Police went to the Park, found him and arranged for an ambulance to take him to the City Hospital. They went to the Hospital and stayed there for a short period, until they learned that the medical staff planned to detain him.

However, by 1 am Jonathan still had not been detained. At 1:13 am, police received a call from a nurse to say he had walked out of the hospital. The nurse said he was standing on the Donegall Road, said she was concerned for his safety and asked that police come and pick him up.

Call from concerned nurse not linked to previous incidents.

The officer who took the call circulated Jonathan’s details to police personnel in the area but did not link this to the previous incidents, did not send a police vehicle to get him and did not initiate any proactive inquiries to find him.

“This officer did not ask for even the most basic of details, such as Jonathan’s name, address and why he was being treated in hospital. Even this information alone would have allowed him to connect the call to the previous incidents and correctly identify Jonathan as a ‘high risk’ missing person and initiate an appropriate investigation.

Procedures are that when someone is reported as missing police should assess the level of risk that person is to themselves or to others and take a series of actions accordingly. This did not happen,” said Dr Maguire.

At around 3:30 am, police officers who were attending the City Hospital on another matter were approached by hospital staff concerned about Jonathan, whom they described said as  at ‘high risk and suicidal.’ This information was related back to PSNI’s Belfast Control Room.

The police later visited several addresses. They did not, however, check Jonathan’s home properly:

Inadequate checks at Jonathan's home.

“They spent more than two hours waiting for the specially trained officers and equipment needed to force an entry into his home, only to find that the rear door to the property had been open all the time. This undoubtedly slowed things down during these crucial hours,” said the Police Ombudsman.

But by shortly after 8 am the police had made the connection with the previous incidents that week concerning Jonathan. It was only at this point that police formally recorded Jonathan as a missing person. They visited a number of locations, checked with the City Hospital again and made at least five attempts to contact his mobile number

It was not until shortly after 11 am, more than 9 hours  after they had received the call from the nurse, did police formally assess and record Jonathan as being at ‘high risk.’

Failure to declare Jonathan high risk an unacceptable, significant failure.

Dr Maguire has described the length of time it took the police to make this assessment as an unacceptable, significant failure.  

“Then, having made this assessment, they seemed to have largely ignored it. Under police procedure, officers should contact a Detective Inspector when they have been alerted to a ‘high risk’ missing person. That Inspector would then have responsibility for the investigation from that point onwards. That did not happen, nor did they start a proper missing person investigation.”

By 12 noon police managed to make contact with Jonathan on a mobile phone. Records indicate that there was a lot of traffic noise in the background and that his words sounded slurred, as if he had taken alcohol or medication.  Jonathan said he had walked to Bow Street Mall in Lisburn and was now tired. He said he did not want to meet the police but suggested they phone him back at 6pm.

Phone call no proper basis on which to  change "high risk" grading.

“The officer who took the call did not inform the Duty Inspector of its contents, which would have allowed him to make a fresh assessment of the situation.  Instead, as a result of this phone call, police decided Jonathan was no longer at a ‘high risk’. This was a mistake: a phone call was not sufficient grounds to make such a decision.

Police did not use technology to try and establish an area where Jonathan’s phone had been or, now that he had indicated he was in the Lisburn area, conduct any further searches. The only other inquiries they made were to re-circulate his description, call at his mother’s address and recheck the home of one of his friends,” said Dr Maguire.

At 5:15 police received a report that a man, subsequently confirmed to be Jonathan, had been hit by a train at Knockmore, near Lisburn.


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