I’m not yet aware of any case involving the Right Care, Right Person programme coming under scrutiny in His Majesty’s Coroner’s Courts but we do know it has featured as a background discussion in at least three deaths that I am aware of. We saw an inquest in London after the death of Heather Findlay where the inner London coroner issued a Preventing Future Deaths report after evidence suggested the police would not have responded to a Mental Health Act (MHA) patient who had absconded from the front of a hospital in circumstances where she should have been considered at risk of suicide and her life at immediate risk.
This was a mistake by the hospital, for clarity – the Metropolitan Police were not contacted. However, they stated at the inquest that they would likely not have responded if they had been called due to the new RCRP programme and this led to a fairly lengthy Preventing Future Deaths (PFD) notice expressing concern.
I have wondered for a few months about other cases which have hit the news will also see RCRP discussed, despite the fact the programme was not in play – we know, for example, the tragic deaths in Costessey, Norfolk occurred shortly before the introduction of RCRP and the programme’s commencement in that police force has been suspended in light of events. That remains under investigation by the Independent Office for Police Conduct and we are still to learn what they believe has happened in that case.
NOT COMPREHENSIVE
Meanwhile, news from the Northumbria Police area that Mr James Thompson, HM Assistant Coroner for Gateshead and South Tyneside has issued a PFD notice after the death of Stevyn Carr who contacted the police just after 7pm one evening asking for help. For a range of reasons to do with resources, officers were not dispatched to arrive until a call from his parents expressing concern for his welfare just after 12pm the next day where, very sadly, he was found to have died due to factors including amphetamines and alcohol.
There were various concerns expressed by the Coroner –
- The initial call should have led to attendance within an hour
- There was no review of the inability to achieve this for nine hours
- There was no consideration of alternatives
It was accepted Mr Carr had been “difficult to understand” in his initial call and the coroner stated it was not possible to say what earlier attendance would have achieved but Mr Thompson indicated he had –
“… asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to management of incidents and / or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeless of police response to requests from the public for assistance is improved and is improving.”
RIGHT CARE
The reason for a post linking this to the ideas around RCRP comes from Northumbria Police pointing to the implementation of this programme in their area, from late 2023. What the article does not cover is any comment by the force or the Coroner about how RCRP would have applied to the call from Mr Carr or his family in 2021. We know RCRP means the police do not attend welfare calls around mental health unless there is a crime or an immediate risk to life (IRTL) or risk of serious harm (IRSH) – and yes: broadly considered, drug and alcohol use or misuse is a mental health issue.
So it’s a legitimate question about how this programme works in practice: if someone who is “difficult to understand” rings the police asking for help, will there be a police response or would the police believe that better sits elsewhere? Such a question is difficult to answer in the abstract because it would depend on – very specifically and very precisely – what was said on the phone call. It would also hang on – very specifically and very precisely – what else was known about the caller and / or the address from which they were calling. Another recent inquest, albeit one which has not yet seen publication of a PFD notice, also emphasised the need for due diligence in conducting background checks as part of determining whether there will be a police response or referral to another agency.
Once you’ve done all the intelligence checks and reflected specifically on the exact wording and content of the 999 call, you’re in a position to determine whether the ‘threshold’ for RCRP is satisfied – crime, IRTL or IRSH. What I find interesting and unanswered by the coverage of Mr Carr’s inquest is the question of what would happen now. Northumbria Police is talking about RCRP against a backdrop of the Coroner seeking assurance the public would be helped. But RCRP is about the police not doing welfare checks unless the threshold is met – so would a case like this see urgent transfer elsewhere, to the ambulance service, for example?
LEARNING LESSONS
I suspect we’re going to see more of these kinds of inquests because they’ve obviously started – initially involving incidents which pre-date RCRP’s introduction in the relevant area it seems inevitable we will then see investigation and discussion about incidents which occurred after the programme’s introduction. My own experience with these topics in Coroner’s Courts and when handling operational incidents is that detail and specifics are key – it could hardly be otherwise. And emergency services of all kinds are almost always making decisions in conditions of uncertainty – you don’t always have ideal information or ideal amounts of time to seek information before having to make choices about what you do or do not do.
What has always been true as well is that specifics are often absent from joint protocols, training and policy – this is not (just) my view, HM Coroners have been pointing this out for years and you can see examples of this on my resources page about Preventing Future Deaths. There can’t be much left to learn that isn’t already reflected in previous tragedies where families are still grieving the loss of vulnerable loved ones and so it’s impossible to end a post like this without re-quoting Deborah Coles from Inquest who spoke at the National Policing and Mental Health Conference in Oxford, 2015 –
“The police are not just guilty of failing to learn lessons, but repeatedly guilty of failing to learn repeated lessons.”
I’ve genuinely tried really hard to find a way to disagree with this since I heard her say this – but I’m afraid I can’t.
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 