There are several preventing future death reports of interest to us in a recently published batch on the Chief Coroner’s website, so there will be a few posts in coming weeks to cover them. The first relates to the sad death of Heather Findlay in London in 2020: her inquest concluded earlier this month (June 2023) with a finding of suicide. Once again, it touches on topics which have come up before and relates to someone who absconded from detention under the Mental Health Act 1983 (MHA) who died shortly afterwards.
But it also raises something new.
Heather had been a section 2 MHA patient up until the day of her death on 11th June and had been granted section 17 leave from hospital with a condition she be escorted by a healthcare assistant (HCA). She had similar, escorted leave twice a day since the 1st June, always without incident and it was to allow her to have a cigarette at the front of the hospital (smoking on NHS premises is unlawful, even for detained patients). The coroner for Inner North London reports she was at the front of the hospital with the HCA at 3pm on 11th June having her cigarette when she announced she was “sorry to do this to you” and ran away. The East London mental health trust reported her missing to the Metropolitan Police at 3:17pm.
Heather was found by a member of the public at 3:58pm, the implication being she was found deceased, albeit that detail is not made clear in the notice.
MATTERS OF CONCERN
His Majesty’s Coroner noted six matters of concern, most of which often have bearing on considerations around policing where reports are made of patients who are Absent without Leave under the MHA. They included —
1. The HCA did not consider following Heather — she reported the events to the senior duty nurse and by that time, Heather was no longer in view so she returned to the hospital. The Coroner mentioned that whilst there may be some safety factors involved for staff, they should make a judgement about following patients who leave their escort. Police officers have often been known to mention this: it’s so much easier for other people to find someone if a member of staff who is following can pinpoint the patient’s location, obviously. The PFD notice covers who policy in that mental health trust is changing on this point, but she raises questions about the detail of it.
3. Police response — the Metropolitan Police stated in evidence an absconded patient who is being followed by a member of staff may not necessarily lead to a police response at all. The coroner stated “that concerned me”. The argument was put forward: various professionals have the same legal powers as the police to re-detain an AWOL patient under section 18 MHA but the coroner then made extremely practical remarks about how this might prove difficult in practice, at least for now.
4. Right Care, Right Person was expressly mentioned — the Metropolitan Police stated in evidence they are looking to roll out the operational model from Humberside Police, as are a number of forces. She made a number of observations about this, in the context of Heather’s death:
“I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.”
JOINT PROTOCOLS
You’ll remember some of the reaction from mental health organisations, charities and others to the Metropolitan Police’s announcement in May they would stop attending emergency mental health calls by September 2023 unless it involved an immediate risk to life. This inquest also shows up the difficulties in understanding in quick time whether a particular case might involve such a risk and highlights the trust got it wrong. There was considerable discussion during evidence of whether Heather would be classified as medium risk or high risk by the trust and whether the police would just adopt the trust’s risk assessment as their own, once reported. That debate can rage but the pertinent point in the learning from this inquest appears to be the jury’s finding – noted in the PFD report itself – there was a failure by the trust to recognise Heather was at “imminent risk of suicide”.
If you read my previous post about the legal concept of “immediate risk to life” you will have noticed discussion of the Supreme Court case of Melanie Rabone. I won’t repeat the post except to say an “immediate risk to life” does not necessarily just mean “imminent” risk of suicide. There can, in law, be an “immediate risk to life” without someone’s suicide being “imminent”, but in Heather’s case the jury found that imminence should have been identified, ergo it was an immediate risk to life situation. That said, the fact it is such a situation doesn’t mean it is only the police who can or should respond, but the coroner’s practical questions in response to point 3, above, then become live issues. The basis of the finding of an immediate risk to life was Heather’s previous suicide attempt prior to admission and a sudden, unexpected change in behaviour by running off despite have had similar, escorted leave twice a day for almost a fortnight prior to her death, without incident. Ultimately, Heather died within an hour or so by the mechanism attempted prior to her being ‘sectioned’ under the MHA.
The MHA Code of Practice (England, 2015; Wales, 2016) requires police forces and their relevant statutory partners to have joint protocols covering five topics for the effective operation of the Mental Health Act – including one for AWOL patients. The Coroner’s PFD outlines how the police and mental health trust in this case have managed to create conditions within which each would expect the other to act, in circumstances where there is no available detail for how patients such as Heather would be safeguarded in practice. If the paradigms are to be redrawn about how the interface works in policing and mental health, it seems necessary to ensure joint protocols for MHA procedures are complete, as a priority – some areas don’t have such protocols and many have been questioned in other inquests. And as they also showed, it’s not just about the existence of protocols – it’s also about the detailed quality of them, how well known they are to operational staff and how they are monitored and overseen for their effectiveness.
The five areas of business are —
- Section 136 and Places of Safety
- Mental Health Act assessments (eg, in private premises) – inc s135(1) warrants.
- AWOL patients – inc 135(2) warrants.
- Conveyance of MHA patients.
- Section 140 Mental Health Act.
These are not the only areas where joint understanding would be crucial, but they are the five areas mentioned by the Codes of Practice. This is the first preventing future death report I’ve seen which expressly references RCRP and raises some concern.
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, 2023
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 