Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0143, written 15 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jan 2019 |
|---|---|
| Reference | 2019-0143 |
| Deceased | Catherine Horton |
| Coroner | Sarah Ormond-Walshe |
| Coroner area | South London |
| Category | Mental Health related deaths |
| Organisation named | South London and Maudsley NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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5 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Cressida Dick Commissioner for the Police of the Metropolis New Scotland Yard 35 Victoria Embankment Westminster London SWIA 2JL L [ CORONER Tam Miss Sarah Ormond-Walshe, HM Senior Coroner, South London jurisdiction CORONER’S LEGAL POWERS 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act | are =n INQUEST: Ms Catherine Anne Horton LI | cRcUMSTAN CES OF THE DEATH A jury found the medical cause of death was: 1a) Suspension II) Paranoid Schizophrenia How, by what means and in what circumstances, when and where did the death occur: The evidence shows Miss Catherine Horton died in ee. sometime between the 16th and 24th of July 2017, by hanging herself, as a paranoid schizophrenic patient under section 3 of the Mental Health Act 1983. It is reasonable to expect that Catherine should have been under the direct care and supervision of Gresham 1 Ward, Bethlem Royal Hospital. The evidence suggests that the circumstances which contributed to Catherine's death were as follows: - Catherine absconded frorn Bethlem Royal Hospital at 01:36 on the 10th July 2017. - There was a failure by ward staff on night shift duty from 9th July 2017 - 10th July 2017 to adequately observe Catherine, note her absence and report her absconsion. - The administrative EPJS was ineffective in recording the date of receipt and content of notes Catherine handed to staff. These notes were known to be Catherine's primary method of communication whilst on the ward. They failed to be correctly fed into the relevant patient notes and reports. - Catherine's risk assessment was not correctly updated and did not accurately reflect the risks that were relevant in her case. - The grab pack prepared on the 10th July 2017 to assist the police was unacceptable and contained serious omissions and inaccuracies. - The management structure of the ward failed to provide adequate leadership and to correctly delegate responsibility to individuals to co-ordinate the safe return of Catherine to the ward. - There was a deficiency in the understanding of how to execute a section 135(2) warrant once it was obtained. This led to an unacceptably long period of time between obtaining and executing the warrant. - The above failures and omissions were causative of Catherine's death. - There was no effective care plan for Catherine We cannot say one way or the other if this failure was causative of Catherine's death. Conclusion: A suicide conclusion proved on the balance of probabilities, to which neglect contributed. CORONER’S CONCERNS The MATTER OF CONCERN is as follows. - During the course of the investigation, the evidence has revealed a matter giving rise to concern that in my opinion means that there is still a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. There were multiple failures in the days leading up to Ms Horton’s death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Well check had been undertaken). This occurred at a time when staffing was low and the | expectations of the Officer or Officers working on particular days was well above | what was achievable. Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries. I strongly suspect that resources are stretched in every department of the MPS, However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and I am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being relocated elsewhere and the senior officer giving evidence said that the error was made due to pressure of work. I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally. | | 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. Iam asking the MPS to ensure the missing persons unit has sufficient Officers working in it at busy times, so as to make their job achievable, and to minimise the likelihood of mistakes happening. ly Hook RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 12" March 2019 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. If you require any further information or assist: ‘ontact the Coroner’s Officer, on! 8 | COPIES and PUBLICATION | T have sent a copy of my report to the following Interested Persons: The family of Catherine Horton [ South London and Maudsley NHS Trust rt Police Conduct Tam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. [DATE] [SIGNED BY CORONER] 15" January 2019 DP foresve
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
METROPOLITAN POLICE PROFESSIONALISM HQ Miss Sarah Ormond-Walshe, Matthew Horne Senior Coroner, Deputy Assistant Commissioner South London Coroner’s Office, 6" Floor 2" Floor, Davis House, New Scotland Yard Robert Street, Victoria Embankment Croydon, London CRO 10Q SW1A 2JL Coroner’s Clerk: Email: | Tel: 020 7230 1417 Your ref: 01/CO0/19/000249 Our ref: IX/83/17/ 1902_23 Date: 14th March 2019 “Deer Miss Gruuncl - oatahe , | am Deputy Assistant Commissioner Professionalism in the Metropolitan Police Service (MPS). | write in response to your Regulation 28 Report to Prevent Future Deaths dated 15'" January 2019. Your report was sent following the conclusion of the inquest into the death of Ms Catherine Anne Horton. In drafting this response the relevant subject matter experts have been consulted, principally: Detective Superintendent a South Area BCU Safeguarding; Detective Chief Inspector NN Safeguarding (Transformation); Assistant Commissioner HEE | rontline Policing and Chief Superintendent (ga Transformation. Response to Matter of Concern: There were multiple failures in the days leading up to Ms Horton's death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Weill check had been undertaken). This occurred at a time when staffing was low and the expectations of the Officer or Officers working on particular days was well above what was achievable. Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries. | strongly suspect that resources are stretched in every department of the MPS. However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and | am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work. ! am asking the MPS to ensure the missing persons unit has sufficient officers working in it at busy times, so as to make their job achievable, and to minimise the likelihood of mistakes happening. The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017. The MPS has now implemented a programme to incorporate thirty two boroughs into twelve Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges. The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment to what is acknowledged as an area of risk. Under the delivery of this new policing model for London, each BCU has established a MPU that is resourced according to local demand. Each MPU works to a set of minimum standards of operational procedure, staffing levels, skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders. This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular. MPUs are located within a new BCU Safeguarding Hub, which has combined policing units that deal with the most vulnerable together under a single command structure. This allows the local safeguarding senior officer, who is a Detective Chief Inspector rank in the Safeguarding Hub, to take a holistic approach to short and longer-term risk management. The local Duty Detective Inspector has the flexibility to increase officer numbers in the MPU at times of high demand due to the flexibility of the new BCU model. Safeguarding hubs also deal with mental health, child sexual exploitation and referrals from local authority adult and child safeguarding services. The MPS has invested significantly in safeguarding focused police officer posts as part of the new BCU model, which has resulted in an increase of dedicated MPU officers. The MPUs are now integrated with local command and control functions via a local operations room in each BCU that monitors live and incoming risk at all times. Any new missing person who comes to the notice of police will continue to be risk assessed and monitored by the emiérgency response team Duty Inspector. Any high-risk missing pérson will immediately be passed to the Safeguarding MPU under the direction of a Detective Inspector who will utilise all relevant and available resources to ensure priority actions are addressed. Safeguarding investigation teams across London are resourced 24 hours a day following the implementation of a corporate shift pattern. This delivers greater operational resilience to the Duty Inspector overnight to ensure that crucial lines of enquiry can be conducted with the required urgency. Following the implementation of BCUs, led by the Assistant Commissioner for Frontline Policing, the Deputy Assistant Commissioner for Local Policing will conduct a three month review of their progress; this provides the opportunity to check that all the elements of the BCU including MPUs are working effectively. This will be followed by a full review (June to September 2019) and recommendations will be provided on how to further improve the model taking into account pressures that have been experienced and address any risks or issues that have been identified. The MPS has reviewed and updated its policies and standard operating procedures for on- going risk-assessments, investigations and interviews with returning missing people. Interviews with returned or found missing people are aimed at prevention of further missing episodes. Information that could prevent the person going missing again, along with any other information affecting their welfare, is disseminated to our policing and partner agencies, which allows for early intervention. investigator toolkits have been updated and are now readily available via response officers’ standard issue mobile-devices. Further advice and support is available from a safeguarding officer attached to every BCU Operations Room, who will have had the safeguarding induction course and will be substantive detectives. All officers posted to MPUs must attend a mandatory week-long training course that was redesigned in 2018 and is now being delivered to officers in every BCU. Three day bespoke training is also being delivered to BCU Duty Inspectors. South Area (SN) BCU incorporates the boroughs of Croydon, Sutton and Bromley. The South Area MPU has had an uplift of officers with a pian to increase staffing levels further in the near future. High risk missing person cases should attract a BCU response and a senior detective within the Safeguarding Hub will lead the investigation. There are currently some challenges regarding the investigation of low and medium graded missing person reports before they reach the MPU, however this is now being addressed as a matter of urgency. In Conclusion Since 2017 the MPS has undergone a significant restructure with the implementation of a BCU model. BCUs now have dedicated Safeguarding Hubs staffed by trained officers and a chain of command that addresses the changing demands of each BCU in order to manage the day to day risks. The MPS has invested in additional staff in MPUs and provided access to 24 hour support to afford the necessary flexibility and resilience to the investigation of missing persons. | trust this provides the reassurance that the MPS has considered the points you have raised, and that we have moved promptly to make such improvements. Please do not hesitate to contact me if | can be of further assistance. Yours sincerely, Deputy Assistant Commissioner
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