Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0008, written 20 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2020 |
|---|---|
| Reference | 2020-0008 |
| Deceased | Deborah Lamont |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
CORONER’S OFFICE GRAEME HUGHES THE OLD COURTHOUSE HER MAJESTY’S COURTHOUSE STREET ACTING SENIOR CORONER PONTYPRIDD SOUTH WALES CENTRAL CF37 1JW CORONER AREA Telephone: 01443 281100 Facsimile: 01443 485862 Email: Coroneradmin@rctcbc.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Constable of South Wales Police & The Chief Executive of the College of Policing 1 CORONER I am Graeme Hughes Acting Senior Coroner for South Wales Central 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 04/04/2019 I commenced an investigation into the death of Deborah Margaret LAMONT. The investigation concluded at the end of an inquest on 17th January 2020. How, when & where she came about her death were found as follows:‐ On 28.3.19 Deborah Margaret Lamont has travelled to the Village Hotel, Whitchurch. There, at some time after 9.40pm she has tied a ligature around her neck and suspended herself from an anchor point above the entrance door. She was found deceased by South Wales Police Officers just after 11pm. The evidence was sufficient to determine that she intended the consequences of her actions to be her own death. My conclusion was Suicide 4 BRIEF CIRCUMSTANCES OF THE DEATH SWP officers attended room 161 at the Village Hotel at approximately 23:05 on Thursday 28/03/19 in response to a report from Hotel staff, concerned for the guest Debbie Lamont (DL). Staff had been unable to get a response from Debbie and when opening the door to her room they believed that she was slumped behind the door and were unable to open the door further than a few inches. Upon officers arrival staff used a key card to open the door and it was noted that a white bed sheet was wrapped around the overhead fire door closer which was attached to something heavy behind the door and inside the room. Officers have at this point tried to remove the sheet however it was taut. Officers managed to slide inside the room and found Debbie slumped on her knees facing the bathroom with the bed sheet tied in a noose around her neck and suspending her slightly against the door. She was limp, cold to touch & pale. There were no obvious signs of a disturbance. Officers have commenced CPR chest compressions and rescue breaths and applied the defibrillator pads to her for around 10 minutes until Paramedics arrived. The defibrillator repeatedly advised no shock was advisable and to continue CPR. Eventually Paramedics arrived and continued with CPR for around 30 minutes eventually declaring ROLE at 23:43 hours. DL had experienced a suicidal episode earlier in the day in the hotel where response officers have attended. They have noticed that she was upset, sat with tights tied around her neck and superficial scratch's to her wrists. Paramedics attended and she spoke with the police control room Mental Health supervisor at the time. It was determined that she would be able to stay at the hotel as follow up mental health contact would be arranged. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. 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 report to you. The MATTERS OF CONCERN are as follows. – (1) The Inquest focused upon the response of the emergency services ‐ SWP, WAST & CTMUHB Mental Health Nurse, to the earlier suicidal episode. Evidence was received from amongst others, of SWP, – paramedic from WAST & Mental Health Nurse, regarding their involvement with DL. gave evidence as to his interpretation of s136 Mental Health Act 1983(MHA). In particular, whether he believed that the power to remove DL arose in the particular circumstances he was presented with on the evening of 28.3.19. In summary, his interpretation of s136 was that, even if he had been satisfied that DL was suffering from a mental disorder & in immediate need of care, or control, the power to detain would not have been available to him, due to the exclusion in s136(1A). His interpretation of that sub‐section was that as DL had paid for the hotel room in which she was staying, that was a room in which she was living. Regard was had during the Inquest as to the Department of Health Guidance to the changes to the MHA 1983, published in October 2017. No specific guidance as to the classification of a hotel room for the purposes of whether that falls within the exception in s136 (1A) is provided. Whilst it is accepted, both by myself, & in the Guidance, as above, that there will always be some degree of discretion for a police officer to exercise in relation to the interpretation of whether a person is living in a hotel room, the evidence here was that DL had booked into the room for one night & had no more than a bare licence to occupy it (which would contrast with, for example, an individual or family temporarily housed in a hotel room by a local authority, or a care home resident occupying indefinitely a room in a care home). Hence, based upon the evidence I received, and my interpretation (in these particular circumstances) of whether a hotel room came within s136 (1A) MHA, I found it likely that did have the power to remove DL to a place of safety My concern is that faced with a similar situation (albeit in circumstances were the officer did consider a person was suffering from mental disorder and requiring of immediate care, or control), an officer may reach the same conclusion as determine the power to remove did not exist, and this may lead to a risk of death to that individual. I would emphasise that whilst I interpreted s136 MHA as likely to afford the power to remove DL on the night in question, I found his assessment of DL to be a reasonable one, and that the grounds to remove her did not exist as she was not in immediate need of care, or control. (2) I consider that it is necessary for the police to consider their interpretation of whether a hotel room falls within the exception provided for by s136 (1A) MHA, and to provide clear guidance, and instruction to officers faced with exercising their powers under s136 MHA in circumstances were an individual presents with suffering from mental disorder, is requiring of immediate care or control and at that time is located in a hotel room. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th March 2020. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the College of Policing, the Local Health Board Mental Health Team and the family who may find it useful or of interest. I am 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. 9 20/01/2020 Signature Graeme Hughes Acting Senior Coroner South Wales Central Please note that the office is open between 8.00 a.m. and 4.00 p.m. on Monday to Friday only. Telephone queries outside these hours and days may not be able to be dealt with until the office is next open.
2 responses 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.
CADW DE CYMRU’N DDIOGEL « KEEPING SOUTH WALES SAFE Coroner's Office 11 MAR 2020 Received we x Og, WN 2 ai i is iy eid | a = AN! Ws SS vemees |) = <a CAN Biers Temporary Assistant Chief Constable ca area South Waies Police South Wales Police Headquarters Cowbridge Road Bridgend CF31 3SU 10" March 2020 Mr Graeme Hughes Acting Senior Coroner Coroner’s Office: South Wales Central The Old Courthouse Courthouse Street Pontypridd CF37 1JW Re: Deborah Margaret LAMONT Deceased Dear J a ( | write on behalf of the Chief Constable of the South Wales Police in response to the Prevention of Future Deaths report of the 20 January 2020 in relation to Deborah Margaret LAMONT (deceased). Your notice under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 sets out your concerns which may be summarised as:- 1) Whether s136 could have been legally used in a hotel room if the officer concerned felt it was necessary to do so and; 2) For the Police and College of Policing to consider their interpretation of whether a hotel room falls within the exception provided for by s136 (1A) Mental Health Act (MHA), and HEDDLU DE CYMRU SOUTH WALES POLICE Pencadlys Heddlu De Cymru, Heol y Bont-faen, Penybont CF31 3SU South Wales Police Headquarters, Cowbridge Road, Bridgend CF3) 3SUI Mewn argyfwng ffontwch 999, fel arall, ffoniweh 101 In an emergency always dial 999, for non-emergencies dial 101 Gwefan: www.heddlu-de-cymru.police.uk © Website: www.south-wales.police.uk Maza Heddiu De Cymru yn croesawu derbyn gohebiaeth yn Gymraeg a Saesneg. South Wales Police welcomes receiving cotrespondence in Welsh and English, Byddwn yn ateb gohebiseth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd = Any correspondence received In Welsh will be answered in Welsh and corresponding gohebu yn Gymraeg yn arwain at oedi. in Welsh will not lead to a delay in responding. Prif Gwnstab! EE QPM, MA(Oxon)MSc. Chief Constable to provide clear guidance and instruction to officers faced with similar circumstances. The report was sent to the Chief Constable and the Chief Executive of the College of Policing and we have had the benefit of being copied into the response a Faculty Lead for Uniformed Policing, College of Policing dated 3 March 2020. As you are aware, the College of Policing was established in 2012 and its purpose is to provide those working in policing with the skills and knowledge necessary to prevent crime, protect the public, and secure public trust. They hold three complementary functions namely Knowledge, Education and Standards. The latter function includes the maintenance of Authorised Professional Practice (APP). APP is the official source of professional practice on policing. Police officers and staff are expected to have regard to APP in discharging their responsibilities. We note that the College of Policing has sought its own legal advice to assist in the provision of a response and have shared your view that s.136 was an available option in this instance but there is no legal basis to mandate this. The Chief Constable also notes that whilst you interpreted s.136 as likely to afford the officer the power to remove Dr Lamont on the night in question, his [the officers] assessment of Dr Lamont was a reasonable one and the grounds to remove her did not exist [at that time] as she was not in immediate need of care or control. The Chief Constable notes that the College will circulate a summary of this issue to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. It is noted that in addition, the College has raised the issue with the Home Office and will work together to assess the need for relevant changes to the current national guidance (APP) in relation to the use of $136 and hotel rooms. The College will ensure that all Forces are kept appraised of developments. The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc. It is hoped that this response combined with that of the College of Policing will address the issues and concerns as set out in your report. Yours Sincerely TACC as
Mr Graeme Hughes HM Acting Senior Coroner for the area of South Wales Central The Old Courthouse Courthouse Street Pontypridd CF37 1JW 3rd March 2020 Re: Deborah Margaret LAMONT Deceased Dear Mr Hughes, I write on behalf of the College of Policing in response to the Prevention of Future Deaths report of the 20 January 2020 in relation to Deborah Margaret LAMONT (deceased) who sadly lost her life through suicide in 2019. The notice sets out concerns that arose from the information received during the inquest into the death of Deborah Lamont. We are very sorry to read of the circumstances of Deborah’s death and our sympathies are with her family and friends. We share your commitment to addressing the issues that have been raised following her untimely loss. When dealing with such incidents, the duty of care shown by officers to the individual concerned is always paramount and we welcome any findings and recommendations to ensure that the highest standards are maintained. Your notice sets out your principle concerns namely: 1) Whether s136 could have been legally used in a hotel room if the officer concerned felt it was necessary to do so and; 2) For the police to consider their interpretation of whether a hotel room falls within the exception provided for by s136 (1A) Mental Health Act (MHA), and to provide clear guidance and instruction to officers faced with similar circumstances. In this case, the officer’s interpretation of s136 MHA was that the power to detain was not available to him as he believed that, having paid for the hotel room in which she was staying, Deborah Lamont was ‘living’ there. This can cause confusion as there are occasions and situations where some people do ‘live’ in hotels, for example when they have been displaced following serious incidents and are subsequently housed in hotels by Local Authorities. In these cases there is no doubt that the people in the hotel are clearly ‘living’ there. The use of s136 MHA is prohibited “in any house, flat or room where that person or another person is living.” When the Home Office and Department of Health produced guidance for the 2017 amendments to the MHA1983, the document did not contain any reference to hotels. That guidance states that in most situations it will be obvious whether or not s136 applies, “however in other situations it may be less-clear cut”. As this is a matter of law, the College has sought its own legal advice to assist in providing this response. The advice received agreed with your assessment that someone “living” in a room implies that the person normally resides in that place and is not there temporarily. There are no definitions provided within the legislation and no stated cases that assist in providing clarification. Consequently, the use of s136 in these circumstances is a subjective one and requiring individual assessment and interpretation. In other words, the use of s136 in the case of Deborah Lamont could have been a consideration. In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments. I hope that this addresses the concerns that you set out in your report and I am grateful for you bringing them to my attention. Yours sincerely Faculty Lead Uniformed Policing
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.