Agnès Marchessou

Date of report	26 Nov 2020
Reference	2020-0255
Deceased	Agnès Marchessou
Coroner	Mary Hassell
Coroner area	Inner North London
Category	Suicide (from 2015) · Mental Health related deaths
Source	judiciary.uk record · original PDF
Responses published	none published

The report

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.

METROPOLITAN
; POLICE

PROFESSIONALISM HQ

Deputy Assistant Commissioner

Coroner ME Hassell New Scotland Yard
Senior Coroner Victoria Embankment
Inner North London London

St Pancras Coroner’s Court SW1A 2JL

Camley Street

London N1C 4PP Email:
Tel:

Your ref:

Date: 5'" February 2021

| am responding on behalf of the Commissioner of Police of the Metropolis to your Regulation 28
Report to Prevent Future Deaths, dated 25th November 2020 as the Deputy Assistant Commissioner
(DAC) for Professionalism in the Metropolitan Police Service (MPS). Your report was sent following
the conclusion of the inquest into the tragic death of Ms Agnes Marchessou.

The Directorate of Professional Standards Specialist Investigation Unit (DPS SIU) conducted an
investigation into police contact with Ms Marchessou prior to her death on 14"" July 2020. A Death or
Serious Injury (DSI) investigation report was compiled by the MPS, following a determination by the
Independent Office for Police Complaints (IOPC) that this investigation should be conducted by the
MPS. Various sources of evidence, including, but not limited to, the statements of the investigating
officers, crime reports, accident reports, Computer Aided Despatch (CAD) messages and other
material were considered as part of that investigation and are referred to below.

A senior manager of the officers who dealt with the road traffic collision (RTC), has held meetings
with those officers concerned to identify any additional learning and to assist with providing a
response to the points that you have raised.

The response to the matters of concern is as follows:

An officer of the rank of Chief Inspector has spoken with the two officers who attended the RTC
involving Ms Marchessou.

The officer who provided evidence at the inquest was one of two officers who attended the scene.
This officer was less experienced at investigating RTCs than the officer he was accompanying. He
was in his probationary period at the time. It is not unusual in these circumstances for the junior
officer to be responsible for completing the necessary paperwork and reports for such incidents. They
would take details at the scene of the collision in order to gain more experience of this aspect of
policing.

In referencing the two officers at the collision, | will refer to the police officer who provided evidence
at the inquest as Officer 1 and the officer he accompanied as Officer 2.

Matters of Concern

One of the police officers interviewed the bus driver, who told him that Ms Marchessou had
stopped when the bus driver sounded his horn, but then had stepped straight in front of the
bus, and after she had been hit had got up and run in front of another bus, only being saved
when a passer-by grabbed hold of her. The police officer did not pass on this crucial account
to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of
the doctors or nurses at the hospital.

Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms
Marchessou in the ambulance. This would be normal practice where two parties were involved, with
each officer initially dealing with their casualty, witness or other party involved. The senior officer has
discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the
decisions he made. It was evident from their discussion that the officer was reflective as he
recognised that he would deal with a similar incident differently next time. He would now relay the
bus driver's account to his colleague who was dealing with Ms Marchessou at the scene and
subsequently provide this information to the medical staff at the scene and at the hospital.

The officers had the responsibility to share relevant information with the LAS, who could: have
provided medical assistance pertaining to her mental health. It should also be noted that the LAS
were already on scene when the officers arrived and would therefore have undertaken their own
. primary survey, which should have included discussion of Ms Marchessou’s health and wellbeing,
together with any relevant history.

Both officers have reflected on this failure with their senior officer and have committed to enguring
more effective sharing of such vital information in the future. (ea RSW FF
Ms Marchessou told the police officers that she had blacked out and could not remember
what had happened, then that she thought she had stepped into the road as the result of a
panic attack. She also said that she had stepped in front of the bus because she was upset
about being denied contact with her children.

Officer 1 does not recall the second sentence being a part of what was said to him directly. It would
appear that these comments were not witnessed by the officer and this may have been as a result of
later discussions by other parties.

Officer 2 has stated that Ms Marchessou told him and the LAS crew in the ambulance that she had
blacked out/had a panic attack and stepped out in the road in confusion. There was no mention that
Ms Marchessou had intended to self-harm.

The MPS identified that the officers should be reminded of the need to share information from both
parties, to ensure that consideration can be given to any additional risks identified. This is reflected in
the response to question 1 above. It is unclear though, if Officer 1 understood the information
provided to them by the bus driver in the same way that the bus driver intended. This therefore may
have affected the decisions made.

| am of the view that both officers have learned from this incident.

The two police officers waited with Ms Marchessou at the hospital for well over two hours, but
did not at any point during that time radio police control to ask for any enquiries or searches
of police systems to be made. Such information could have been potentially extremely helpful
to those treating Ms Marchessou.

Officer 2 has confirmed that he did in fact request checks of police systems whilst waiting at the
hospital via his personal radio. He was informed of the domestic incident and the bail conditions
applied to Ms Marchessou. It would appear that despite this information coming to notice, neither
officer completed the Merlin report. The officer has been spoken to by the Chief Inspector,

acknowledging that they would do things differently in the future and as identified in the matter above,
would complete a Merlin report in future.

Officer 2 acknowledged that had he known of the bus driver's comments he would have approached
the way they dealt with the incident differently and would in all likelihood, have completed a Merlin
Adult Come To Notice report (ACTN).

| am satisfied that that both officers now understand the vital importance of communication at the
scene of an RTC and have learned from this incident.

When the police officers returned to the police station, they did make a search themselves
and discovered that she had been arrested for domestic violence. However, they did not make
a Merlin record of her potential vulnerability and need for assistance

There would appear to be some misunderstanding on the part of the officer as previously indicated in
the responses above, as to the essential nature of the incident. This may have impacted ultimately on
their perception of risk related to the incident. | am satisfied that there was sufficient cause for
concern in respect of her mental health for it to be discussed. This should have prompted completion
of a Merlin Report. Officer 2 states his understanding after speaking to a supervisor was that it would
simply be dealt with as a RTC report. Both officers have learned from the incident.

The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the
circumstances in which reports should be completed. This also references the Vulnerability
Assessment Framework (VAF) which should be used as the basis for assessment for all officers.
This assessment is based on appearance, behaviour, communication/capacity of the victim and
whether the victim is in danger and the environment/ circumstances they are in. The MPS considers
that this action will support officers in making appropriate decisions in respect of completing Merlin
Reports for vulnerable people.

| was provided with a statement from one of the two police officers in advance of the inquest
and | called him to give oral evidence on 25 November 2020. When | put to him the sub optimal
nature of the way that he had dealt with the incident on 8 July 2020, he did not appear to have
undertaken any reflection on this in the intervening four and a half months, nor in thie witness
box.

If there was any error in not passing on information, he attributed this error to his colleague.
He did not consider that he had failed to apply a healthy degree of scepticism to Ms
Marchessou’s version of events, particularly in the light of the bus driver’s description. He
reiterated the view he had formed on the day, that Agnés Marchessou being hit by a bus was
purely an accident.

The police officer defended all of his actions robustly. | could not see that he had learnt
anything as a result of these events or that anything about his practice would change in the
future

The officer has acknowledged this in subsequent meetings with a senior manager and has already
sought support from several sources to increase his understanding of incidents, and to improve the
quality of the written evidence and investigation that he undertakes.

The police officer giving evidence was aware of the view of the Directorate of Professional
Standards (DPS) regarding the failure to create a Merlin, expressed in its report on the police
handling of the incident on 8 July, but he seemed very confused about how that should work
in practice. If he is confused, even after police have taken him through the DPS report, then
other police officers may also be confused.

As above, MPS is providing a toolkit to support officers in making their assessment of risk and the
creation of Merlin reports. It is anticipated that this will be introduced within the next month.

Additional actions

The MPS is committed to ensuring that it learns from tragedies as Ms Marchessou’s untimely death.
A small team of dedicated officers is developing a Suicide Prevention Policy Document and Toolkit.
The publication of this policy is a key step in developing our co-ordinated strategy to suicide
prevention. The policy will draw together information on suicide prevention, support services, risk
indicators, contacts and best practice. It will be accompanied by a toolkit providing easy to access
guidance and advice from signposting support services to identifying key partners. A draft external
Suicide Prevention Policy is due to be submitted through the MPS'’s internal policy development
process.

In addition to the policy publication, the suicide prevention team is committed to improving the
training and guidance available to all officers and staff. An investigative standards’ document which
forms part of the toolkit, is under development and is designed as an easy to follow key points to
consider document for police first responders. This will enhance knowledge and understanding
across the entire service and build on the additional guidance that is already used by some teams
where death by suicide is considered higher risk i.e. Custody, Online Child Sexual Abuse.

The MPS Suicide Prevention Team is also meeting with other police forces to learn and share good
practice.

In Conclusion
| wish to express my condolences to the family of Ms Marchessou.

| trust this provides the reassurance that the MPS has considered the matters of concern you have
raised. Please do not hesitate in contacting me should you have any queries.

Yours sincerely

Yom Yossie

Deputy Assistant Commissioner

Also filed under 2020-0255: Agnes-Marchessou-Prevention-of-future-deaths-report-2020-0255_Published.pdf

Regulation 28:  Prevention of Future Deaths report 

Agnès Blandine Marthe MARCHESSOU (died 14.07.20) 

THIS REPORT IS BEING SENT TO: 

1.  Commissioner 

Metropolitan Police Service (MPS) 
6th Floor, New Scotland Yard 
Victoria Embankment 
London SW1A 2JL 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 29 July 2020, I commenced an investigation into the death of Agnès 
Blandine Marthe Marchessou. The investigation concluded at the end of 
the  inquest  on  25  November  2020.  I  made  a  narrative  determination, 
which I attach. 

4 

CIRCUMSTANCES OF THE DEATH 

Agnès Marchessou 

.  She had suffered fragile mental health for the four or five years 

leading up to her death.   

On 4 July 2020, she was arrested for assault following a domestic 
incident.  On 8 July 2020, she was knocked over by a bus.  Police and 
ambulance services attended and she was conveyed to hospital. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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.  

Metropolitan Police Service officers attended Ms Marchessou on 8 July 
2020, after she had been knocked over by the bus. 

1.  One of the police officers interviewed the bus driver, who told him 
that Ms Marchessou had stopped when the bus driver sounded 
his  horn,  but  then  had  stepped  straight  in  front  of  the  bus,  and 
after she had been hit had got up and run in front of another bus, 
only being saved when a passer-by grabbed hold of her.   

The  police  officer  did  not  pass  on  this  crucial  account  to  the 
emergency ambulance crew who transported Ms Marchessou to 
hospital, nor to any of the doctors or nurses at the hospital. 

2.  Ms Marchessou told the police officers that she had blacked out 
and  could  not  remember  what  had  happened,  then  that  she 
thought  she  had  stepped  into  the  road  as  the  result  of  a  panic 
attack.    She  also  said  that  she  had  stepped  in  front  of  the  bus 
because  she  was  upset  about  being  denied  contact  with  her 
children.   

The police officers did not pass on the crucial information that Ms 
Marchessou said she had stepped in front of the bus because she 
was upset about being denied contact with her children, either to 
the  emergency  ambulance  crew  or  to  the  treating  doctors  or 
nurses. 

3.  The two police officers waited with Ms Marchessou at the hospital 
for well over two hours, but did not at any point during that time 
radio police control to ask for any enquiries or searches of police 
systems to be made.   

Such information could have been potentially extremely helpful to 
those treating Ms Marchessou. 

4.  When  the  police  officers  returned  to  the  police  station,  they  did 
make  a  search  themselves  and  discovered  that  she  had  been 
arrested  for  domestic  violence.    However,  they  did  not  make  a 
for 
Merlin  record  of  her  potential  vulnerability  and  need 
assistance. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  I was provided with a statement from one of the two police officers 
in advance of the inquest and I called him to give oral evidence 
on 25 November 2020.  When I put to him the sub optimal nature 
of the way that he had dealt with the incident on 8 July 2020, he 
did  not  appear  to  have  undertaken  any  reflection  on  this  in  the 
intervening four and a half months, nor in the witness box.   

If there was any error in not passing on information, he attributed 
this error to his colleague.  He did not consider that he had failed 
to  apply  a  healthy  degree  of  scepticism  to  Ms  Marchessou’s 
version  of  events,  particularly  in  the  light  of  the  bus  driver’s 
description.  He reiterated the view he had formed on the day, that  
Agnès Marchessou being hit by a bus was purely an accident.   

The police officer defended all of his actions robustly.  I could not 
see that he had learnt anything as a result of these events or that 
anything about his practice would change in the future. 

6.  The police  officer giving  evidence  was  aware  of  the  view  of  the 
Directorate of Professional Standards (DPS) regarding the failure 
to create a Merlin, expressed in its report on the police handling 
of the incident on 8 July, but he seemed very confused about how 
that should work in practice.   

If  he  is  confused,  even  after  police  have  taken  him  through  the 
DPS report, then other police officers may also be confused. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that 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 25 January 2021.  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 following. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   HHJ Mark Lucraft QC, the Chief Coroner of England & Wales 
  MPS Directorate of Professional Standards 
  PC 
  PC 
  Dr 
  Mr 
  Mme 

, Whittington Hospital Emergency Unit 
, husband of Agnès Marchessou  

, mother of Agnès Marchessou 

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

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. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

27.11.20                                              ME Hassell 

4

The report

Related reports

Other reports by Mary Hassell

More reports categorised “Suicide (from 2015)”

Track Suicide (from 2015)