The coroner in my home area issued a very sad Preventing Future Deaths report in February 2024 which has just been published on the Chief Coroner’s website. It relates to the conveyance by ambulance of a young patient who had been detained under section 2 of the Mental Health Act 1983 (admission for assessment) and who subsequently jumped from the back of a moving ambulance in Worcestershire and died of her injuries. The PFD notice itself is sent only to the Chief Executive of West Midlands Ambulance Service but if you read the whole thing, you may find yourself unclear as to why it is not also sent to senior figures in the the NHS mental health trust, the local authority and to the Chief Constable, because the events have bearing on the trust and on local authority Approved Mental Health Professionals – and it ends with implications for the police who weren’t even sent a copy of the notice.
In inquests juries are often set a series of questions to answer by the Coroner and many of them will be closed questions requiring a ‘YES’ or ‘NO’ response. In this particular PFD, rather unusually, the Coroner has set out all of the questions which were asked so we can see a lot of the detail. However, the summary is, Rosie was assessed in Worcester and deemed to require admission under s2 MHA. An inpatient bed was identified at a hospital in Redditch, a twenty-five mile drive away and an ambulance was requested to convey. It took thirteen hours after the request for the ambulance to arrive and paramedics were then responsible for moving Rosie from Worcester to Redditch. Somewhere towards the beautiful village of Inkberrow, she jumped from vehicle and subsequently died of serious head injuries in a Birmingham trauma unit.
The many questions asked by the Coroner of the jury made certain things plain:
Rosie had jumped from moving vehicles before and this had not been factored in to the decision to ask paramedics to convey. In addition, paramedics were not sufficiently aware of a transportation policy in the county and AMHPs were also inadequately trained in it. The jury found the thirteen-hour delay in an ambulance arriving should have caused a risk assessment to be re-done concerning the safety and appropriateness of ambulance conveyance, but this did not happen. In the end, the jury found these various failures and several others did cause or contribute to Rosie’s very sad death.
The final question asked is extremely interesting:
“If your answer to Question 11 above is NO, which one of the following options should have been used?
– Mental healthcare staff provided by HWHCT to travel in the back of the ambulance vehicle with Rosie?
– Police officers to have travelled in the back of the ambulance vehicle with Rosie? YES”
The jury believe the police should have accompanied the patient in the ambulance with paramedics and this is where it all becomes really interesting, including because I wondered about the basis of why the coroner asked that question as the police have no more powers in this situation than paramedics or mental health professionals who could have been asked to undertake the function and police restraint techniques are not considered appropriate for clinical settings. The NHS has access to private providers to provide therapeutically-relevant, more dignifed conveyance and that goes unmentioned in the report.
LEGAL POSITION
Various things need saying, or reminding –
- Once an MHA application is made for admission, the person detained is in legal custody and it’s the AMHP’s legal custody.
- The effect of the application means the AMHP has authority under section 6 MHA to “take and convey” the patient to hospital and they may delegate that authority to others.
- However, they cannot compel others to accept the delegated authority and the Code of Practice to the MHA makes clear (paragraphs 17.10 in both the English and Welsh Codes) that a joint protocol should exist to cover these matters.
- I will have to assume the “Mental Health Act transportation policy” referred to in the PFD fulfils this function for Worcestershire and I can’t find it online to see what it says.
- Reference to the police in chapter 17 of the Codes (which deals with conveyance under the MHA) makes reference to the involvement of the police becoming justified where a patient is “violent or dangerous”.
The local policy is therefore key: what precisely has the Chief Constable of West Mercia agreed to? – the policy may include provision of officers for this purpose because Rosie does appear to have had a history of jumping from moving vehicles and there is an obvious danger in that, both to her and to other road users depending on how it happens. That said, other Coroner’s have had something to say about conveyance situations involving the police, even where resistance and attempts to jump were manifest, and there are ways to plan around the need for officers to become involved.
In 2011, police were involved in the admission process of Mr Alan Bailey in Greater Manchester who also tried to jump from a moving ambulance and was restrained by the police officer in the ambulance. There was significant criticism of the decision to handcuff Mr Bailey, but the criticism went further than that – extending to questions about why the police were involved at all. If the NHS had used a relevant secure transport provider, there would have been no need.
RIGHT CARE, RIGHT PERSON
The publication of this PFD in to the death of Rosie Young comes at a point where all police forces in England have been told to have the “Right Care, Right Person” initiative up and running by the end of 2024, if they haven’t already and whilst some forces have commenced phases one and two of the programme, phase three is about conveyance so it will touch directly upon the issues flagged in this PFD. Ultimately, in law, it is the responsibility of the Integrated Care Boards in England and the Local Health Boards in Wales to commission transport services to meet their patients’ needs – this includes their mental health patients, some of whom will be resistant to admission in various ways. Risk of jumping from a moving vehicle is just one type of risk to consider, we also know conveyance by ambulance has led to a patient smashing up a 999 ambulance where paramedics had little choice but to get out, lock the vehicle and call the police and in others, paramedics have been assaulted.
That all needs discussions ahead of phase 3 of RCRP so everyone is clear about what will and will not be done, not only by the police but also by the agencies who are legally responsble for various things. The main legal nuggets I focus on in cases like this are –
- The patient is the AMHP’s legal custody
- ICBs (or LHBs) are legally responsible for commissioning transport for their patients.
- This includes for their mental health patients, whose needs may be different from those requiring a traditional, yellow ambulance.
- Obligations arising from human rights as well as health & safety laws impose a duty on those organisations to plan, prepare and risk-assess their reasonably foreseeable activities.
- The police do have certain obligations: but they will no doubt be couched in the RCRP world as arising from the so-called ‘threshold’ in the National Partnership Agreement.
- The ambulance service, who also have responsibilities to around human rights and health & safety are under no direct obligation to accept the AMHPs delegated authority under s6 MHA.
- And neither are the police.
So if I worked in Worcestershire in any of the above organisations, I’d be asking my boss questions about the local policy, about the above legal nuggets and about how that will all be untangled in a way which reflects to RCRP world which must be heading their way at some point soon, if it hasn’t started already. If I were a paramedic, I doubt I would ever accept legal authority to convey someone – it’s simply nothing I can be compelled to do and I would suggest paramedics are not trained in those matters relevant to ensuring that is completed safely.
There are plenty of perfectly foreseeable situations which will crumble as this one did, unless those things are squared away in an appropriate local policy and unless front-line professionals from AMHPs to paramedics to police officers understand the law – especially if the local policy is not the same thing as the law. It’s worth noting as an aside, many areas which have introduced RCRP do not appear to have formally revised their joint operating protocols to reflect the post-NPA world and this can only possible create confusion and contradiction for the front-line professionals working in those areas.
You might wonder what could possibly go wrong?
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 