Still Too Many Questions

I wrote last week about three separate process which had concluded after adverse events involving the police and their response to mental health calls. I mentioned the conclusion of the inquest in to the sad death of Joseph Phuong and couldn’t say much about it as details weren’t covered in the media. I heard about this case shortly after it happened, when discussing policing and mental health matters with the Metropolitan Police and had awaited the inquest, interested in the view that would be taken of how events had unfolded – but I was aware I didn’t know anything like the full picture and I still don’t. I don’t know whether the Coroner will issue a ‘Regulation 28’ Preventing Future Deaths report, but I would imagine, if it’s coming, it will be worth reading. The IPCC have also suggested they’d review whether or not they can publish their report in to the conduct of Metropolitan Police officers and I await that decision with equal interest because there seems more to reflect on in this case.

Last week’s post was essentially bemoaning the fact that adverse outcomes resulting from a combined NHS and police response to a mental health emergency often reach a point where all we focus upon are problems with policing. I do understand why that is and the post was in no way an attempt to insist there are no problems in policing – there are perfectly understandable instincts to ensure that people are held to account following someone’s unexpected death and a genuinely held view that this doesn’t occur in cases where it should (that’s argued to be a problem in policing and in healthcare, incidentally). Last week, the gross misconduct hearing after the death of Seni Lewis led to his family calling for a meeting with the Commissioner and if that had been my son who died, I’d want that, too. I have no issue with it as there are things to discuss with the police and it never does harm for officers at any level to take time to listen.  I just also hope there is a request to meet with the Chief Executive of the relevant mental health trust, because there are issues and listening lessons there, too.

Today, the first media coverage emerged after the Inquest in to Joseph Phuong’s death – a Guardian interview which straight away proved my point from last week’s post. See the header image, above: it is a screenshot from the Guardian which begins, “The sister of a man with schizophrenia who died in police custody” … I had to stop reading there, initially but then quickly noticed the headline writers had better understood the incident and made no mention of the police. Joseph Phuong died in Springfield Hospital in south-west London whilst detained under the MHA by the NHS and after they had restrained him, forced him to received medication and removed him to a seclusion room. He wasn’t in police custody in either sense: he was not in a cell block, he was not under arrest or detained by the police in any other building, like a Place of Safety. Yes, his admission to hospital occurred via a route that involved the police, yes the police had also used restraint during that process – yes, that all needs looking at if someone died. Ultimately, the article manages to get it right: it’s clearly states towards the end of the article Mr Phuong arrived at Springfield Hospital ‘in the early hours’ (just after midnight, according to other public reports) and was restrained by NHS staff shortly after 2am. He was secluded and medicated against his will during that process and 2hrs later he was found collapsed (despite being on constant observations) and afterwards pronounced dead at A&E.


The Independent Police Complaints Commission launched an independent inquiry in to Mr Phuong’s death. They have not published their report or their findings, except to say that no officers will face no misconduct proceedings, arising from this tragic incident. The Guardian reports Mr Phuong was first of all taken to A&E by ambulance with a police escort (presumably on a voluntary basis?) and left that location after arrival. So my first question would be to wonder about whether the grounds for using s136 were met during this first encounter and that’s obviously a question for the police – it will be interesting to learn whether the inquest record or the IPCC report says anything on this point and it’s the only question I’ve got for the police in my understanding of this incident. But if the Guardian had done just a little more digging, they would have discovered suggestions already in the public domain that go beyond what they have reported in their article on other parts of the narrative —

The London Evening Standard, reporting shortly after the tragedy, stated that there was then a second reason for the police to become involved and that Mr Phuong was detained under s136. It is inferred there was a delay for an ambulance – knowing some of the issues in London around ambulance conveyance after use of s136, I admit to wondering if they did arrive at all? The Standard mentions something else the Guardian doesn’t – an attempt was made to take him directly to a mental health unit (MHA Place of Safety, presumably). Only after that was he taken to St George’s A&E department. Did he access the Place of Safety or was he turned away? – no mention was made at the start of any additional medical factor indicating A&E would be necessary. Whilst there, it is alleged Mr Phuong assaulted a police officer and he was arrested and taken to custody, where he know he remained for many hours after his Mental Health Act assessment indicating he required admission. I’m guessing there was a bed problem which meant it remained necessary for him to stay in police custody until that was resolved, still under frequent restraint by officers. In all fairness, an eight-hour delay for a bed isn’t a big delay these days, but it’s still a delay that means police custody and more restraint.

Eventually, Mr Phuong was admitted to hospital, almost twenty-four hours after the police first encountered him, during which time he has experienced five separate period of restraint, according to the reporting. A sixth episode of restraint by NHS staff occurs two hours prior to him being found collapsed, during which time he was also given medication against his will. How do we untangle all for this, for necessary accountability and for the organisational learning that needs to occur?! First, we need to start by accepting that in any circumstances where the police and the NHS are struggling to come together quickly and effectively, it needs to be a joint review. I admit to wondering how that is reinforced if following a death there are questions about ambulance responses, place of safety access, timeliness of Mental Health Act assessments and the availability of inpatient beds?


The Standard reports the IPCC will now consider whether they can publish the report of their investigation given the inquest has concluded – I’ve also asked them to consider doing so and look forward to learning their decision. One thing we should bear in mind: there have been recent examples of the IPCC using their legal powers to direct forces to hold gross misconduct hearings for officers, even where the original decision by the force was not to do so because grounds weren’t met. Notwithstanding suggestions in the public discussion about the IPCC being the ‘same thing’ as the police, I can assure you many officers take a different view, based on certain cases they have seen where the independent panel appointed to hear a gross misconduct case has dismissed charged amidst suggests that there never was a case to answer. Regardless of that reality / perception debate about police / IPCC relations, I mention it because it does seem likely if the IPCC thought there was any suggestion officers had misconducted themselves, they would have pushed for a hearing because of the amount of criticism they face for not holding the police to account. Yet here is a case where officers were not investigated on any basis of misconduct at all, the officers were not placed on restricted duties or suspended during the investigation.

The police and the NHS owe it to the people we exist to serve and the families of those who have died in state ‘care’, to discuss how we work effectively together, prevent further such outcomes wherever possible and the media owe it families and to the frontline staff who have to do this work, to fairly represent what actually happened to the public so we can avoid a simplistic perception of what went wrong. Joseph Phuong died tragically and there are probably lessons to be learned by all: there always are. But did he didn’t die in police custody and the inquest criticism of the Metropolitan Police doesn’t seem, so far, to suggest the main operational decisions they took were in any way wrong. Nor was police restraint specifically linked to the conclusion of why Mr Phuong died. Ultimately, and perhaps unbearably for his poor family, that was recorded as ‘unascertained’, which is not a verdict we hear very often.

This all comes back to real basics, doesn’t it? – do we have a well understood s136 process in a local area which has capacity to absorb predictable levels of demand and allows the frontline staff from these agencies to come together quickly over important issues, minimising the need for restraint and maximising the clinical oversight of people who are to unwell to be left in the care of police officers with first-aid certificate? I genuinely hope this less-reported case is given a higher profile than it has had so far, because it strikes me putting a sharper focus on common problems that some would say are only becoming more frequent issues in many areas and which will become more acute once the law changes in December – but only if those who report on it and going to take time understand the issues and research the events involved before they confuse and distort anything further. I always hope in these matters that families at least feel they’ve had answers as to what happened and why. Can only hope that’s the case.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019

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.

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