Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0176, written 7 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2019 |
|---|---|
| Reference | 2019-0176 |
| Deceased | Simon Robinson |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | Police related deaths |
| Organisation named | Oxford Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable Francis Habgood QPM, Thames Valley Police, Oxford Road, Kidlington, Oxford, OX5 2NX chief.constable @ thamesvalley.pnn.police.uk CORONER lam Mr D M Salter, HM Senior Coroner for Oxfordshire. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION AND INQUEST On 22 January 2019 | conducted the inquest into the tragic death of Simon Robinson who died at his home address of n2 February 2018. | returned a Narrative Conclusion as follows: Simon Robinson, aged 52, died on 02/02/2018 at his home address 20 Bridge Street, Oxford, being formally pronounced deceased at 15.43 hours. Simon Robinson had a long-standing mental health history of schizoaffective disorder and was suffering a psychotic episode when at approximately 14.27 hours he stabbed himself in the neck with a kitchen knife causing him to exsanguinate. Given his psychosis at the time he may not have been capable of forming a real intention to end his life. At about 14.27 hours his wife phoned 999 to request police attendance but the call was incorrectly graded resulting in a delayed response at approximately 15.15 hours. Given the likelihood that the injuries were sustained at about 14.27 hours it is possible but not likely that an immediate deployment and a response within 15 minutes may have enabled emergency medical treatment to have prevented his death. Thames Valley Police were legally represented at inquest. In addition to Mr Robinson’s family, other ‘Interested Persons’ included Oxford Health NHS Foundation Trust (OH). Evidence was collated prior to inquest and a copy of the inquest file was provided to your legal department. The evidence at inquest included oral evidence from the police controller and, importantly, from Chief Superintendent Christian Bunt. Prior to inquest, | was provided with a copy of TVP’s Critical Incident Review dated 17 July 2018 and a witness statement of Chief Superintendent Bunt dated 22 January 2019 along with other TVP documentation. | attach a copy of the review and statement for ease of reference. CIRCUMSTANCES OF THE DEATH As will be seen from the above, Simon Robinson stabbed himself in the neck while suffering a psychotic episode at his home address on the afternoon of 2 February 2018 and bled to death. made various telephone cails to TVP and OH. tiInmG x spoke to the police controller at 14.27 hours and despite her concerns about her safety, she was advised to contact OH which she then did. Her concerns were not immediately escalated at OH either. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make this report to you. | should say that Chief Superintendent Bunt was a helpful and frank witness who provided helpful evidence. | appreciate that this matter raises difficult considerations involving communications between, for example, police and mental health services and also issues surrounding the extent of police powers. The MATTER OF CONCERN is in relation to the following: The concern that | have is mirrored in Chief Superintendent Bunt’s statement paragraph 57 where it states that the current partnership agreement does not adequately cover incidents such as this one. The problem is the not uncommon situation where a person is experiencing a mental health crisis and there is an imminent need for agencies to respond. If the person is experiencing the mental health crisis is in their home or another private place, police powers are limited. | recognise there is a requirement to work in partnership with other agencies but the primary responsibility to respond when there is a fear for welfare or safety rests with the police. It should be the expectation therefore that the police will respond initially to deal with matters until other agencies are able to respond and take over if appropriate. It is concerning that there is a gap in the partnership agreement for a crisis situation such as this. | understood from Chief Superintendent Bunt that there was a need to formalise a plan at a strategic level to include consideration at inter-partnership meetings. It would be reassuring if the issue could be reviewed in this way and an action plan or similar agreed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. — YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. | may extend the period on request. 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. COPIES and PUBLICATION | confirm that a copy of this report and your response will be sent to Mr Robinson's family. 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. Signed Date ik Mert. lei4 HM Senior Coroner for Oxfordshire
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.
THAMES VALLEY John Campbell QPM Pp oO L : Cc e CHIEF CONSTABLE Thames Valley Police HQ Oxford Road Kidlington OX5 2NX Mr D.M Salter HM Senior Coroner, Tel: 01865 541881 Oxfordshire Coroner’s Office, The Oxford Register Office, chief.constable@thamesvalley.pnn.police.uk gnd floor, www.thamesvalley.police.uk 1, Tidmarsh Lane, Oxford. 2 May 2019 OX1 1NS Dear Mr Salter, Re: Inquest into the Death of Simon Robinson Response to Regulation 28 Report/Prevention of Future Deaths Thank you for your report sent by letter dated 7 March 2019 in respect of Simon Robinson deceased, pursuant to Regulations 28 and 29 Coroners (Investigations) regulations 2013 and paragraph 7, schedule 5 Coroner’s and Justice Act 2009. Your report contains the following matter of concern: “the current partnership agreement does not adequately cover incidents such as this one. It should be the expectation therefore that the police will respond initially to deal with matters until other agencies are able to respond and take over if appropriate. It is concerning that there is a gap in the partnership agreement for a crisis situation such as this.” We note that you would be reassured if the issue is reviewed at an inter-partnership meeting and an action plan agreed. Response to the Regulation 28 concerns The Interagency Partnership Agreement (Protocol), between Thames Valley Police (TVP) and Social Care agencies has been carefully considered and reviewed to address the concerns which have been raised. As a result a number of suggested amendments have been made to the Protocol, which are: 1. Where police receive information that a person is suffering a significant mental health crisis where there is an actual or potential threat of serious harm to that person or others, the police will provide an immediate response in the first instance 2. The help of the appropriate Mental Health Agency will be sought at that time 3. The lead health agency when notified, will take ownership for the care of the person concerned as soon as possible 4. The priority for Police officers is to prevent serious harm to the person concerned and others at immediate risk 5. When first contacting the lead health agency a single point of contact will be established to aid communication with the Police Serving with Pride and Confidence 6. Where a health agency receives information that a person is at immediate risk of harm to themselves or others, they will carry out a risk assessment and immediately inform the Police with the risk assessment and relevant information. 7. In recognition of the limitation of Police Powers in certain situations, there is an overarching principle that the Police will seek to discharge its core responsibilities to save life and protect persons from harm. With the welfare of the individual(s) concerned at the heart of any decision making. A strategic Mental Health partners meeting was held on 2nd April 2019. The recommended amendments were disseminated to all relevant Mental Health and NHS Agencies for consultation at this meeting. A response is expected from all agencies by 30th April 2019. The Protocol must be fully agreed by all parties before any changes are implemented. It is proposed we will be able to report back to the Coroner in June 2019 with the outcome of the consultation and any agreed changes to the Protocol. It is the intention of Thames Valley Police to instigate amendments 1:2:4:7 with immediate effect. These are changes to operational guidance for Thames Valley Police which can be implemented irrespective of amendments to the multi-agency protocol. | trust this response complies with your requirements. However, please do not hesitate to contact me should there be any further queries. Yours Sincerely Jet Guibed John Campbell Chief Constable Thames Valley Police Serving with Pride and Confidence
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