Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0055, written 10 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2020 |
|---|---|
| Reference | 2020-0055 |
| Deceased | Kerry Aldridge |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Railway related deaths · Suicide (from 2015) · Mental Health related deaths |
| Organisation named | South London and Maudsley NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. South London and a NHS Foundation Trust: 2. Metropolitan Police Service: CORONER Iam Andrew Harris, Senior Coroner, London Inner South jurisdiction CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INQUEST L opened an inquest into the death of Ms Kerry Aldridge, who died on 6 April 2019 at Sydenham Railway Station (00969-2019). An investigation was opened on 10.04.19 and an inquest was opened on 25" April and was concluded on 9" October 2019, A decision on whether to send a report was delayed by the process securing a transcript and awaiting interested persons to make submissions, which ultimately was not taken up. The medical cause of death was: la Multiple Traumatic Injuries. The conclusion was suicide. CIRCUMSTANCES OF THE DEATH The deceased was a student police officer. Safeguarding officers discussed her mental well being with her on 27" March, after an allegation of a crime. On 4" April, police officers were alerted to her high risk of suicide by jumping in front of as train, and found her at a railway station and took her home and spent time with her. Two days later she returned to the station and jumped into the path of a train. CORONER’S CONCERNS During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. P| the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support. The MATTERS OF CONCERN are as follows. - It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the evidence given in the inquest about the circumstances of this death and are in a position to mitigate or prevent future deaths: South London and Maudsley NHS Trust Metropolitan Police Service YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6" April 2020 I, the coroner, may extend the period. If you require a: the case officer, ny further information or assistance about the case, please contact COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: BE other PE (aches MEE Mother Iam also sending this report to the following, who have an interest, Secretary of State for Health, NHS England and Royal College of Psychiatrists. | 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. Lp [DATE] [SIGNED BY GOROWER] “be am, 10thFebruary 2020 Andrew Harris /Sénior Coroner
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.
Nursing Directorate
Trust HQ
The Maudsley Hospital
Denmark Hill
London
SE5 8AZ
Tel: 020 32282602
31st March 2020
Dr Andrew Harris
HM Coroner
Southwark Coroners Court
Dear Sir
Inquest touching the death of Kerry Aldridge – PFD Response
I am writing to you on behalf of South London & Maudsley NHS Foundation Trust
(SLaM) in response to the Preventing Future Death report issued on 10th February
2020.
On behalf of the Trust I acknowledge your concern in regards to this very sad incident
which resulted in the tragic death of Ms Kerry Aldridge
In preparing this report I have consulted with the following:
-
-
-
Inspector
Adult Safeguarding, ANVA Tactical Policy Advisor
, Metropolitan Police, Central Mental Health Team,
Inspector
, British Transport Police, Public Protection.
, Clinical Service Lead, SLaM Acute Referrals Service (Crisis
Assessment Team)
The Provision of further Mental Health Training for Metropolitan Police Officers.
In my discussion with
I was informed that all Metropolitan Police
officers receive training in mental health and mental capacity issues. We both
acknowledged that there maybe specific officers who would benefit from more focused
training. She specifically identified officers who would have a dedicated role in suicide
prevention. I was able to identify that as a mental health trust we are able to provide
mental health awareness training to a range of community partners. Our Mental Health
Promotion team provide Mental Health First Aid training and there is an option for the
Metropolitan Police to commission this training package. Preliminary discussions are
due to take place by the end of March 2020.
Mental Health Support to Metropolitan Police Officers
identified that the Metropolitan Police do not have a
Safeguarding Adult Team, however, there are safeguarding strands attached to all 12
of the Borough Command Units. South London & Maudsley NHS Trust Foundation
Trust employ two full time Metropolitan Police officers who work within our main
hospital sites and liaise on a three monthly basis with the borough command
safeguarding officers who all have mental health knowledge and experience. The
officers employed within our mental health trust would usually act as a conduit for
information, advice and support within our service but also their fellow officers in the
borough command units
assured me that officers have a range of personal support
internally ranging from counselling to well- being advice and signposting to appropriate
support services.
Single Point of contact
I am pleased to identify that there exists a strong link between SLaM & the Metropolitan
Police. On a wider perspective, there are a number of pathways that police officers can
assess support and advice in relation to early identification of individuals who may
need specialist mental health interventions
South London & Maudsley NHS Trust has, since 2017, worked in partnership with the
Metropolitan Police to provide a crisis and assessment service. The service enables
mental health staff to work jointly with metropolitan police officers in the provision of
, allocates officers to work
early assessment and intervention.
within the Crisis and Assessment team. The service also provides a 24 hour advice
and support line to the public, 111 service, the police and London Ambulance Service.
The advice line is staffed by mental health professionals who will advise officers and
instigate rapid joint assessment if required. This joint arrangement between the police
and South London & Maudsley NHS Foundation Trust offers a proactive joint response
to the concerns that may face police officers who may have limited knowledge in
relation to mental illness.
The Crisis and Assessment Team covers the four boroughs served by South London
& Maudsley NHS Foundation Trust, Lewisham, Southwark, Croydon, and Lambeth. In
addition, there is a Pan London S.136 telephone advice and support line. Although,
aimed at providing advice to police officers considering the use of their powers under
Section 136 of the Mental Health Act 2007 the line is promoted as the mental health
single point of access.
The support line is staffed by Medical Professionals & Paramedics. The British
Transport Police Public Protection and Vulnerability team may also be available to
assist as a consequence of accessing this help line.
The British Transport Police Vulnerability Unit provides a joint partnership approach
with an NHS Provider to actively reduce and prevent railway suicides. The NHS mental
health workers are embedded in the team and provide mental health support and
advice to British Transport Police and Metropolitan Police on request. The mental
health workers will liaise with the police and the individual’s GP, local health, and social
care provider to ensure that they are aware of the person’s vulnerability. This service
has a wide geographical reach.
I have attached relevant documents that illustrate the services available to the
Metropolitan Police to assist in formulating their concerns in relation to mental health.
Summary
In documenting the services provided by South London & Maudsley NHS foundation
Trust in conjunction with the Police I hope that there is sufficient evidence to conclude
that there is ongoing collaborative work between the NHS and the police. There are
clearly elements that need to be enhanced one of which may be the provision of Mental
Health First Aid to specific officers in designated roles.
Yours faithfully
Director of Nursing (interim)
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