A coroner has ruled Kent Police missed an opportunity to deploy a mapping system that could have located a teenager who called them in distress before taking his own life.

Alan Blunsdon's conclusion brought an end to a three-day inquest into the death of Matthew Mackell, a 17-year-old school boy who died in Dunorlan Park in Tunbridge Wells on May 6, 2020.

At the third day of the hearing at County Hall in Maidstone today, Mr Blunsdon also said he would be writing to Kent Police urging them to make further changes to staff training policies to prevent a similar tragedy from occurring again.

The cause of death was recorded as suicide but giving a narrative conclusion the coroner added: "At 10.18pm on May 6 Matthew phoned Kent Police to inform them of his intentions but he did not provide his identity or location.

"Kent Police did not deploy the available mapping system that would have provided an accurate location. This was a missed opportunity.

"They did not maintain the current immediate grading of the call and did not dispatch a patrol in response to the call.

"It is not possible to establish in the balance of probability if the mapping system would have led to a patrol finding him before he was found deceased."

The statement came after the inquest revealed staff in the control room who spoke to Matthew that night had no knowledge of an enhanced mapping system that could have provided a more accurate location to his whereabouts.

This new system has now been made the default position and a number of other changes by Kent Police have since been introduced, but the coroner felt more focus still needed to be put on staff training.

It comes after all members of police staff who gave evidence at the inquest said they did not remember receiving any guidance on how to deal with calls relating to the risk of suicide.

Mr Blunsdon said as a result, Kent Police should look to find a better system in which logging the training for the individuals is easier to track.

If it shows training has not been completed, he would like it to now say why and give reasons for the gaps.

Summing up, the coroner added it was a concern the mapping system was not deployed and said it was a direct result of the absence of proper training which was "clearly a systematic failure".

Reflecting on the hearing, Michael Bond, Matthew's father, stated: "The inquest showed that Kent Police had the ability to accurately pinpoint where Matthew was, and so urgently help him – but that they did not do that as their staff were ignorant of, and had not been trained in, how to access a crucial feature of their computer mapping systems.

"This was a major and, as the coroner determined, systemic failing by Kent Police. I believe had they sent someone to Dunorlan Park, they may have found and helped him.

"The inquest showed Kent Police did not treat Matthew’s calls to them as a suicide risk, and, heartbreakingly, his calls were downgraded as less important.

"It is helpful that officers of Kent Police have admitted that was the wrong thing to have done, and not in accordance with their policies.

"Matthew was an amazing young man, and a wonderful son, and we will miss him forever.

"We are heartbroken. No family should ever have to suffer the loss of their child, knowing that they called for help and no one came.

"I remain very worried that if this type of incident happens again, that staff may not be aware of guidance or procedure, and may not be appropriately trained. Kent Police still don’t seem to have enough training, even a year after Matthew’s death.

"We are relieved that the coroner is going to write to express his concerns, which we share with him, to Kent Police, about training of police officers.

"I believe there needs to be urgent action to prevent any further tragedies like this and to stop any other families experiencing what we have been, and continue, to go through.

"If the death of our Matthew can achieve anything by way of change, that would be at least some small consolation."

The inquest follows an investigation by the Independent Office of Police Conduct which identified 'a number of failings' by the force that night.

On the night of May 6, 2020 Matthew called police in distress saying "Can you send someone to pick me up, I’m about to kill myself”.

After the distressing phone call at 10.18pm, Matthew hung up.

The call handler PSE Amy Hopper called Matthew back five minutes later and Matthew had told her he was now 'fine'.

"If the death of our Matthew can achieve anything by way of change, that would be at least some small consolation."

Despite his answer she told him she had heard him say he wanted to kill himself and gave her name as 'Amy'. She then asked him 'what’s your name?' and he hung up.

Checks made against the phone number to identify Matthew came back with nothing and the control room's team leader PSE James Gregson, also phoned him back in an attempt to offer help.

Through silences Matthew asked 'What do you mean help me?' before hanging up again.

Concerned for the caller's welfare, PSE Gregson then marked the call as "immediate" and transferred it to the dispatch team tracing it as coming from an area near Dunorlan Park based on coordinates.

PSE Gregson then told the hearing from this moment, it was his expectation that a patrol would be sent out.

But the team in the dispatch office then downgraded the call from 'immediate' to 'high' priority based on the search area being so vast and the only available action was to keep 'contacting the phone for updates and information to identify the caller’.

Giving evidence, PSE Alan Underwood explained the rationale behind downgrading the call was because the search area included a 78-acre park, a six-acre lake and thousands of homes in the Tunbridge Wells area.

If a more precise location was given, PSE Underwood said: "I would have treated it as immediate and sent a patrol. I wouldn't have even questioned it, there's no doubt in my mind about that."

It has since been found that the downgrading of the call was not in accordance with police guidance because there remained an immediate threat to life.

The downgrade was authorised at 10.54pm but no attempt was made to call Matthew back until 45 minutes later at 11.39pm.

Then a text encouraging him to call the station was not sent to his phone until 2.41am.

In hindsight the police staff felt this could have been sent out sooner.

In yesterday's hearing, Mr Blunsdon said had the advanced mapping function been used, it is a probability that the call could have gone to dispatch at 10.28pm, just 10 minutes after Matthew first made contact with police.

While evidence shows patrols were marked as available, he added it will never be known if they were in fact available to be deployed, and if they were, whether they would have been able to reach him in time to save his life.

Superintendent Andy Gadd from Kent Police also gave evidence stating a number of changes have now been introduced, and said he was confident: "If this incident took place again tonight I am sure it would remain as an immediate status and it would be seen as much more of a priority."

Acting Deputy Chief Constable, Pete Ayling said: "Our thoughts very much remain with Matthew Mackell’s loved ones and friends and we continue to offer our deepest condolences to everyone affected by his tragic death.

"Our officers and staff do their utmost to keep people safe, adhere to the highest possible professional standards and put the safety and welfare of members of the public first.

"These areas of learning have now been addressed, to enhance clarity within force policies and guidance around the response to incidents where there is a threat to life.

"Specifically, this includes ongoing learning relating to updates and advances of mapping software, which will assist with calls where no exact location is available."

The force made a referral to the Independent Office of Police Conduct (IOPC) after the tragedy. Its investigation found officers and staff had acted appropriately and in accordance with force policies.

Investigators analysed Matthew's call and all records relating to the incident. They found no-one should face misconduct or unsatisfactory performance proceedings.

A Practice Requiring Improvement process for a police officer and two police staff members has been recommended. This is a procedure where staff can reflect and discuss mistakes.

Matthew's friends are also doing a 100 mile hike of the South Downs Way in his name to raise money for mental health charity Papyrus.

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