Treatment and Care

Six years ago, Nicola Edgington attacked Kerry Clark and Sally Hodkin in south London, seriously injuring Kerry, a 22yr old woman and killing Sally, a 58yr old mother and grandmother. She was prosecuted for murder and attempted murder, convicted in March 2013 and sentenced to life in prison with a minimum recommendation she serves 37yrs. She appealed against this outcome, but it failed. Four hours before the attacks, the Metropolitan Police had contact with Nicola, having been called to a taxi rank in Greenwich and they assisted her to the Emergency Department at Woolwich Hospital where she was seen by a mental health nurse and admitted on a voluntary basis to a nearby mental health unit. She absconded from the unit thirty minutes or so later, and attacked the two victims shortly afterwards as they made their way to work. If you prefer not to read a pile of material, there is a simple, but useful audio / visual summary of this on the BBC news website.

This week, a report has been published by NHS England in to the care and treatment Nicola was receiving from Oxleas Mental Health Trust and this follows publication on the day of her conviction of an IPCC report in to the police contact. That same week,  I wrote a blog which summarises my main observations and concerns from a police point of view and having just re-read it, I now want to provide an update, having seen the NHS England Report. What is interesting about the report, is that its conclusions have been swiftly and robustly rejected by Sally Hodkin’s family who issued a statement via the charity Hundred Families. I also have my own concerns about this report and I noticed that it was leaked to a journalist ahead of publication, who got straight in with the ‘Met Police tried to suppress this report’ and ‘police failures led to killing’ angle ahead of any possible response by any of the parties involved. He didn’t even begin to mention the catalogue of errors by the NHS until much further down his report.

For all these reasons, this post ended up being much longer than the average. It is precisely to allow you to consider things that went unmentioned and to see some things that went uncontextualised to allow you to form your own views about what you think might have gone on leading up to the publication of this report. It may assist in you forming your view to know Sally Hodkin’s family pursued damages in the civil court following what they believe to have been her preventable death – from the NHS, not from the police.  I’m not a detective, as you know, but the dots here seem quite easy to join.


For me, there are three problems I want to highlight – there are loads more problems, but this is what I’m going to focus on because it’s Saturday night, I’m not trying to fix the whole world here and a comprehensive analysis of all this would take weeks! This is a blog about how two junior police officers have been effectively blamed in a confused report for a decision they took which authors say was a ‘root cause’ of Sally Hodkin’s death, when even her family can see that this wasn’t the case at all. —

  • The Mandate – this is a report by the NHS in to NHS treatment and care. We already have an established process by which to hold the police to account and it’s Chief police officers, the Independent Police Complaints Commission and the Courts. Of course, where agencies come together over an incident, there are overlaps but the role of an NHS report is surely to examine how effectively the NHS performed its task in whatever context it was asked to do so? That’s what the IPCC do – they took account of NHS issues in the deaths of Sean Rigg and Seni Lewis but did not purport to investigate them.
  • The Conclusion – the NHS report acknowledges the panel’s lack of expertise in policing (see third paragraph, p7) and suggests for the future that a policing perspective should be included. If it occured to them whilst writing the report, especially in light of the problem they face about the ‘mandate’, then why not ask during the inquiry? The police would have probably come up with someone independent. Notwithstanding, they insist on drawing conclusions which are at best, debatable and at worst, appear disingenuous and obfuscatory.
  • The Leak – this report was leaked ot the Press, albeit we don’t seem to know who leaked it. That having been acknowledged, I’m way beyond interested that the journalism which resulted from it led with the ‘police faiulure’ angle, taking the report at face value and made the policing issues the primary focus notwithstanding the rest of its findings. It also emphasised the dispute and potential legal action between the Metropolitan Police and Oxleas Mental Helath Trust as if the Met should just let an unqualified, inexperiened panel say whatever they like, however questionable or potentially unlawful.


The IPCC and the NHS reports focus heavily on the period of time 0431-0434 on 10th October 2011, the point where Nicola had looked to leave the ED for a second time and where it is correctly argued section 136 could have been applied. Two Metropolitan Police officers had arrived at Woowich ED and waited with Nicola whilst she was booked in to the system. Having then spoken with her in the waiting area and explained their decision they could not stay with her, they made to leave the department. Nicola initially followed the officers out of the department saying she did not want to stay on her own and officers returned her to the waiting room, re-explained that they could not stay and sought her assurance she would remain there until called. She gave that assurance, they felt able to believe her and subsequently left the department. Notwithstanding her distress, no-one can contest that this story includes Nicola remaining, being assessed and being admitted to Oxleas House.

When we look at police decision-making, some things are objectively right or wrong – if the officers who found Nicola after the attacks had not arrested her for murder, this would have been objectively wrong despite the fact that nothing in law says, “when someone is suspected of murder they MUST be arrested for it”. However, a failure to arrest would prevent officers having full powers of search and seizure to secure evidence and it would prevent the ability to consider the need for interview and a host of other implications – in other words, it would have compromised the investigation and further endangered public safety, which we can agree is objectively wrong. The same is true for some mental health crisis calls: if someone is actively harming themselves or trying to hurt others, lacking capacity and unwilling to engage, then a decision not to invoke s136 would be objectively wrong (unless another legal mechanism achieved the same purpose and was to be preferred.) However, in this case the report is arguing that MHA powers should have been used for reasons which no frontline response officer could reasonably be expected to understand – the reports points out how the assessment could have taken a different look at the fact that Nicola was a conditionally discharged patient, presumably with a view to recall. You’d be amazed how many mental health nurses don’t know what conditional discharge is or what difference it might make. As far as frontline police officers are concerned, an assessment is an assessment and if the nurse in ED wanted a full MHA, they could have called one.

A quick point on the fact officers did not undertake a PNC check and were not aware of Nicola’s previous offending history as they escorted her to hospital. I’ll tell you now and for free: not all police officers conduct PNC checks on people they assist to access mental health care. Not all street triage advice or encounters involve a PNC check on the person at the centre of it and I remember the day after the publication of the IPCC report starting a shift with my response team and I asked that room of twenty-five officers this question: no-one in the room said that they would always conduct such a check. This may be alarming, but judgement of conduct at work is partly around measuring that against the standards of competent peers.


So are we saying here that everyone who asks for help must be forced to receive it, notwithstanding their willingness? Bearing the ‘least restrictive principle’ – which goes entirely unmentioned in the report, incidentally! – what are we saying if we’re not saying that? You’ll notice more broadly, as street triage services have developed around the country, many areas are pushing for much less use of s136 MHA – only yesterday I was at a legal seminar where this imperative was being pressed and you only need to get on the internet to see MH trusts berating the police for ‘inappropriate’ use of s136 MHA. None of this stuff is ever really defined, at least not so precisely so that I could stand up in a training event and actually tell front-line cops what is expected of them.

  • If the officers had used s136, it may or may not have still led to admission to a unit from which Nicola could abscond.
  • If officers do not use s136, it does not prevent the triage nurse asking for a full Mental Health Act assessment which could have still taken further time to consider Nicola’s situation.
  • In other words — the report authors see s136 as a gateway to something certain – and as the only gateway to that. This is just demonstrably false and so it cannot, in all logic, be a root cause factor in this attack. It assumes that things always work as planned, which is almist ironic given what they’re engaged in reviewing in this document.
  • The report is at pains to make it clear this is what the authors think should have happened, but they also say it’s a judgement call that reasonable professionals in good faith can disagree about.  This is at best confused and at worst a weak conclusion – it’s the one, or it’s the other.

Look at p76 of the report, which seems a touch disingenuous to me – it is the point where the authors discuss the police decision to escort Nicola to ED on a voluntary basis. They quote from the (14th edition) of the Richard Jones Mental Health Act Manual about the ability to use compulsion on someone who is willing to undertake voluntary admission. What the report does NOT make clear, is that Jones is referring here to voluntary admission to hospital as an inpatient, not to voluntary access to an ED for assessment of whether hospital admission is required. The fact that this quote from Jones is irrelevant to the point they’re making should have been clear from it’s open reference to Section 5 of the Mental Health Act: this section contains two holding powers, one for Doctors and one for registered mental health or learning disabilities nurses. Neither power can be invoked in an ED … he’s writing about section 131 of the Mental Health Act – voluntary hospital admission.

The report goes out of it’s way to selectively represent certain issues. They tell us (on p77) that officers were in breach of the Metropolitan Police’s Standard Operating Procedure by not involving a paramedic in the conveyance. What they don’t say, is that when this was explored by the IPCC (paragraph 189 of their report), the officers gave an account for why they deliberately took this decision: the presence of the ambulance crew was agitating Nicola, Woolwich ED was only a short distance away and they felt it was better to proceed alone. The IPCC fully accepted this – SOPs are not rules, they are guidelines.  I’m going to stop getting picky, although I have list on my notepad several other things I’d want to get picky about if time and space permitted – the post will simply end up being too long, if it isn’t already.


The number one root cause of this murder, according to the report (see p13) is the police decision not to use s136. Like the IPCC, the panel concludes this was a judgement call reached in good faith. It even says, “Given this set of circumstances some Police officers may have applied Section 136 of the Mental Health Act whilst others may not have. The Police Officers involved reached their decision in good faith and were satisfied that Ms A did not meet the relevant test.” But they go on, somewhat illogically, “However, the Panel believes that Ms A could have been placed on a section 136.”  So was this a judgement call, or not?!  If by ‘judgement call’ we mean something where two perfectly competent professionals might quite honestly reach different decisions based on their perception of the same circumstances, then how can it be objectively wrong? The panel stops short of accusing the officers of negligence and we can note they are saying the officers ‘could’ have used s136, not that they ‘should’ have done so. But they point out what could have happened so many times their implication is clear: they’re judging the officers.

The officers could have done any number of other things, in all fairness: they could have stayed with Nicola, in ED, throughout the assessment, without invoking s136 – many police officers across the country do that every day, for various reasons. They could have used s136, of course – but they also could have taken a decision that their discussions with Nicola and with ED staff were sufficient for them to be satisfied that it was appropriate to leave and that they had encouraged ED staff and security to ring if they perceived problems. Indeed, when Nicola was making 999 calls from ED, the Metropolitan Police did ask if things were OK and they were told by the hospital themselves there was no need for the police to return. So if the officers were wrong, were they objectively or subjectively wrong?! … were they actually wrong at all, bearing in mind the IPCC and the NHS report point out it was a judgement call and not certain?!

But here’s the real nub of it for me: three things —

  • If the Metropolitan Police had used s136 there is absolutely no certainty whatsoever that Nicola would have been ‘sectioned’. History is littered with examples of people being detained by the police under this provision and being released for reasons that aren’t immediately obvious to the officers, only for them to end their lives soon after, or to come to 999 attention again almost immediately and be further detained … and THEN sectioned, after a second assessment. The report seems to take for granted that an MHA assessment would have reached a particular conclusion, which is ironic, given how much else went wrong in this case. Despite the Metropolitan Police not using s136, nothing prevented the mental health nurse in ED seeking to convene a full, statutory assessment and nothing prevented it being conducted. They could have chosen to section Nicola and admit her either to Oxleas House OR to whichever other unit they wished. And if it were thought that the absence of s136 were crucial, why did no-one anywhere ask the police to return or escalate that decision to police supervisors. The police were specifically told at 0512 that there was no need for them to return, after specifically asking if support for Nicola was needed.
  • Secondly, if a trained mental health nurse from the liaison team is going to proceed on a voluntary basis by also misunderstanding that mental health law allows compulsion of the willing, what standard are we holding the police to?! This nurse had a three year degree and who knows how many years of experience of doing nothing other than stuff like this … and they were two frontline police with a few hours training. The paragraph, mentioned above, from the Richard Jones Mental Health Act Manual relates to the very scenario facing the MHLN nurse in ED, and not to the one facing the police in ED or elsewhere – the nurse could have requested a full Mental Health Act Assessment and they could have asked the police to return. Ultimately, it could be argued that the officers’ judgement was borne out by the fact that Nicola made it to Oxleas House for admission and absconded after the point where any s136 officers would have left anyway. If we’re arguing that the s136 assessment would have arranged admission to a different kind of unit then it’s just as easy to point out that voluntary admission could have been to another kind of unit.
  • Finally, Nicola was admitted to Oxleas House from ED, arriving at 0637 and remaining unsupervised until she absconded around 29 minutes later. The report details that she was left unsupervised in an assessment area, albeit one where the patient could control the door and choose to leave, if they wished. Nicola did this and spent time in the reception area. She also left reception and went outside during this 29 minutes. The report seems really careful to avoid being precise about what status Nicola had during this time: was she now an voluntary patient of the trust, or not? On the one hand, the ED staff and security had left her with MH trust staff with agreement; but on the other hand, MH trust staff did not engage with her and take her up to the ward where a bed was available for her. The report mentions the absconding policy, which implies she was considered to be a patient of the trust, otherwise she’s just a person at risk. Since the time of this incident, trust policies and procedures have changed around all aspects of these issues and two nurses have been sacked in connection with the period which led to the absconding. In particular, the front door of Oxleas House now has a lock on it! So … it turns out, the murder would have been prevented regardless of what the Metropolitan Police did or didn’t do, if only the trust had a basic security feature that most people would imagine they would already have if they are in the business of admitting people there who have previously killed someone.

Is it possible, we’re over-thinking the complexity of all this?  The major things that went wrong in this case had already occured  way before the Metropolitan Police met this woman on October 10th – and that’s not my opinion, that’s the view of Sally Hodkin’s family who are living with the impact of all this, years after the event and forever more. They are probably the most important people of all.

* Disclaimer — I am not and never have been a Metropolitan Police officer.  I was aware of, but not involved in, discussions between the Metropolitan Police and NHS England about the draft report’s contents and conclusions and, in the absence of her own MH staff officer who was on annual leave, I once compiled a summary timeline of events on 10th October, based on the IPCC report. This was for the benefit of the force mental health lead, Commander Christine Jones QPM, ahead of her attending a meeting about the report, at which I was not present. Beyond that, I had no involvement in any other aspect of this.

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 OBE, 2017

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 –

2 thoughts on “Treatment and Care

  1. Couldn’t agree more. To say that was the root cause is ridiculous. Apparently she agreed to go to hospital voluntarily and as you say in the end did stay and was admitted voluntarily. What the authors think is so magic about a s136 is confusing, presumably, a MHA assessment would have resulted in her being admitted, but that was the same outcome as what actually happened anyway. Presumably the authors expect the police to always use s136, even if someone agrees to go to hospital? I think many peopel would be very unhappy if they thought that every time police were called to someone with mental health difficulties that they automatically ran it through the PNC, particularly when the person is asking for help and then is taken to the place where they can receive that help. And as we all know a s136 doesn’t necessarily result in a section……….I really don’t understand how anyone thought she woudl be OK living alone in the community so long after the initial crime. Even if she was now mentally well, surely she would need lots of support to (hate the term) but ‘come to terms with it.

    Grossly unfair on the officers involved.

  2. Dear Mentalhealth Cop,
    I agree with you that it is far more complex than may at first appear.
    Firstly, should we simply overhaul the entire legislation surrounding mental health and mental capacity, streamline it and simplify everything? In HSJ they have stated that Mental Health is no longer a Cinderella. Well, maybe that is what has been so wrong all these years that there has not been parity of esteem between mental and emotional health and that of physical health. That is now being promised to have major changes.
    Secondly, how would you set up something fresh, bearing in mind that we now have Brexit, we are in the process of new law-making, be it just ratifying EU law already made or in fact making new legislation altogether. Whatever Brexit finally comes about – if it does – we have surely a golden opportunity presented to us to change the way in which policing and mental health as well as physical health is done so that instead of people saying but it is your responsibility not ours that instead we can all help one another and be part of a “do as you would be done by” culture where free will is paramount so long as you are not endangering others with your wishes. When it comes, however, to putting youself into danger, that seems to be where we have most difficulty. Because there is the default of mental capacity until such time as it is shown that a person may have a serious mental disorder, and then their actions might in fact be questioned as to their mental capacity based on known history.
    If in future we can prevent a situation from occurring such as the tragedy that befell Sally Hodkin, we might also consider how mental health patients are not necessarily given optimal support in their daily lives.
    I just hope and pray for solutions.
    Again, I admire you.
    Best wishes

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