Thiago Araujo

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

21 April 2021 

Mr Graeme Irvine 
HM Assistant Coroner, Inner North London 
Poplar Coroners Court 
127 Poplar High Street 
London E14 0AE 

Dear Mr Irvine 

Thank you for your letter of 29 January 2021 about the death of Thiago Araujo.  I am 
responding as Minister with responsibility for mental health and suicide prevention and I 
am grateful for the additional time in which to do so.  

I would first like to say how deeply saddened I was to read of the circumstances of Mr 
Araujo’s death and I offer my most heartfelt condolences to his family and loved ones at 
this difficult time.  

In relation to the concerns you raise about the use of Section 135(1) of the Mental Health 
Act, it is not clear from your report whether the delay professionals expected lay in the 
magistrate issuing a Section 135(1) warrant; in securing an approved mental health 
practitioner and a doctor to be present when the officer actions the warrant; or in securing 
two doctors to carry out an assessment under the Act after the patient has been taken to 
hospital.  However, we expect local organisations, including the police, local authority 
services, and the NHS, to have robust systems and agreements in place to ensure these 
actions are carried out swiftly. 

I am aware that the Camden and Islington NHS Foundation Trust has provided a response 
to your report in which it has explained the action that is being taken to improve the 
responsiveness of the assessment process involving the police and Approved Mental 
Health Practitioners.  I have also been advised that the Trust has taken further learnings 
from the findings of your investigation, in particular, in relation to decision making and 
communication with carers when patients are discharged from the Crisis service due to 
non-engagement; as well as greater assurance that carers and families are routinely being 
offered the support and information they need.        

It is essential that the Trust and local partners take action to learn from Mr Araujo’s death 
to improve the safety and quality of care locally.  

My officials have brought your report to the attention of the CQC which, as you will know, 
is the independent regulator for care quality in England responsible for monitoring and 
inspecting health and care services against the fundamental standards of quality and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 safety, with the ability to take action where providers of services are not meeting their legal 
obligations. 

I would like to assure you that we are taking action nationally to ensure that people with 
severe mental illnesses and people in crisis can access timely support. 

We remain committed to expanding and transforming mental health services in England.  
This commitment is backed by an additional £2.3 billion by 2023/24 through the NHS Long 
Term Plan.  This funding will ensure that at least 370,000 adults with severe mental illness 
have greater choice and control over their care and are supported to live well in their 
communities by 2023/24. 

On the wider matters of your report, you may wish to note that we are working with a broad 
range of stakeholders to tackle emerging suicide methods, including the use of chemicals 
such as Mr Araujo took, and a process has been established with a range of stakeholders 
and across Government to rapidly flag emerging methods and take actions through a 
multi-agency approach.  This includes but is not limited to, limiting access to the method, 
reducing or removing material that promotes its use as a method of suicide, and providing 
clearer warnings of risk. 

With specific regard to the chemical that Mr Araujo used, officials have met other 
Government departments and bodies, academic experts on suicide prevention and self-
harm, and third sector stakeholders, to look at how to tackle the use of this and similar 
chemicals in suicides. 

Officials are informed through these meetings that the chemical used in this case is 
covered by existing guidance from the Home Office on the sale of explosives precursors 
and poisons.  The Home Office regularly engages with suppliers of such chemicals to 
provide detailed guidance in relation to any additional safeguarding steps they may wish to 
take.  Generally, online marketplaces maintain their own policies on prohibited items, 
many of which will include a prohibition on the sale of poisons.  It is the seller’s obligation 
to check that items they are listing are permitted by their own policies and to take any 
action where it is appropriate. 

Significant progress has already been made on limiting the availability of the chemical 
used in this case, for example, in tackling supply of the chemical for non-industrial use.  A 
chemicals supplier is working with Government to alert us of suppliers of this chemical on 
a number of large, online retail platforms.  I am aware also that eBay has decided to 
prohibit globally the sale of this chemical after receiving a report of its potential use as a 
suicide method, and it has improved its block filter algorithms to ensure there are no 
similar listings.  

In addition to work within Government, Samaritans are working regularly with the media to 
educate and improve how incidents of suicide are reported.  This includes working with the 
media on how it reports novel suicide and, in this case, the importance of omitting details 
that raise awareness of suicide methods. 
We are aware also that there are websites that promote, or provide information on, suicide 
methods.  The Department for Digital, Culture, Media and Sport (DCMS) published its 

 
 
 
 
 
 
 
 
 
 Online Harms White Paper1, which set out a range of legislative and non-legislative 
measures detailing how the Government is planning to tackle online harms, including 
harmful materials on self-harm and suicide. 

On 15 December 2020, DCMS published its response to the White Paper consultation, 
setting out how the proposed legal duty of care on online companies will work in practice 
and gives them new responsibilities towards their users.  DCMS also announced that the 
Government has asked the Law Commission to examine how criminal law will address the 
encouragement, assistance and incitement of self-harm. 

NADINE DORRIES 

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL 
HEALTH 

1 https://www.gov.uk/government/consultations/online-harms-white-paper

Baroness Williams of Trafford 
Minister of State for  
Countering Extremism 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

May 2021 

Dear Ms Mazepina, 

Thank you for your email of 7 April to the Home Office relating to the inquest into the death 
of Mr Thiago Araujo following the consumption of sodium nitrite.  I am replying on behalf of 
the Security Minister who has taken a temporary leave of absence for curative surgery  
and I am sorry for the delay in responding to your email.  

I have carefully noted the contents of your prevention of future deaths report and I 
recognise the need for continued awareness raising of the controls around sodium nitrite 
and the obligations to online marketplaces when selling this substance.  

Sodium nitrite has legitimate uses as a food preservative, but because of its toxicity it is a 
reportable poison under the Poisons Act 1972.  This means that it is generally available to 
members of the public without the need for a license, but sellers, including online sellers, 
must take appropriate steps to assess if there are reasonable grounds for suspicion before 
accepting a transaction.  They are obliged to make suspicious transaction reports where 
they have grounds to believe that the sale is for an illicit use.  

The Home Office regularly engages with suppliers to help them meet their requirements 
under the Poisons Act and provide detailed guidance in relation to any additional 
safeguarding steps they may wish to take.  Generally online marketplaces maintain their 
own policies on prohibited items, many of which will include a prohibition on the sale of 
poisons.  It is the seller’s obligation to check that items they are listing are permitted by 
their own policies and to take any action where it is appropriate.  

I strongly believe that we must do as much as possible to safeguard those who may be 
vulnerable to harmful sales of poisons including sodium nitrite.  For that reason, I can 
confirm that the Home Office is aiming to establish a consultation this summer on possible 
amendments to the Poisons Act, which will include more obligations on online 
marketplaces including reporting suspicious transactions within 24 hours.  

We will also continue to work with suppliers to ensure they recognise their obligations 
under the Poisons Act for sodium nitrite.  

Baroness Williams of Trafford

METROPOLITAN
POLICE

PROFESSIONALISM HQ

Assistant Coroner Mr Graeme Irvine

Poplar Coroners Court Deputy Assistant Commissioner
127 Poplar High Street New Scotland Yard
Poplar Victoria Embankment
London London
E14 0AE SW1A 2JL
—n a
Tel:

Our Ref: | |

Date: 8" April 2021

| am responding on behalf of the Commissioner of Police of the Metropolis to your Regulation
28 Report to Prevent Future Deaths, dated 29" January 2021. Your report was sent following
the conclusion of the Inquest into the tragic death of Thiago Araujo who died on 5" February
2020.

The Metropolitan Police Service’s (MPS) Directorate of Professional Standards’ Specialist
Investigation Unit (DPS SIU) conducted an investigation into police contact with Mr Araujo prior
to his death on 5" February 2020. A Death or Serious Injury (DSI) report was completed
following a determination by the Independent Office for Police Complaints (IOPC) that this
investigation should be conducted by the MPS.

The investigation found that Mr Thiago Araujo had been suffering from deteriorating mental
health and had been reported missing by his father on 5" February 2020. Mr Araujo was
believed to bein possession of sodium nitrate which he intended to harm himself with. Mr
Aruajo was declared a high-risk missing person by the MPS and an active search was
instigated. Sadly, Mr Thiago was found deceased at a family address approximately one hour
after the initial missing person report was recorded.

The MPS concluded that no officers had breached any policy guidance or legislation and at
the time no individual or organisational learning opportunities were identified.

The MPS has acknowledged and reviewed all six matters of concern that you have raised and
has sought to address matters five (5) and six (6) as, the appropriate lead agency. The
response to these two matters is as follows:

In evidence the community recovery team indicated that a factor in their inaction was
the knowledge that arranging a section 135 mental health act 1983 warrant and
assessment would take two weeks. Such an assessment requires actions by an
approved mental health practitioner from the local authority, two section 12 mental
health act approved doctors, the assistance of the Metropolitan police and the local
Magistrates Court to secure a warrant. A delay of 14 days in securing a mental health
act assessment is in my opinion unacceptable.

Any delay in securing a Mental Health Act warrant and subsequent assessment would be for
the relevant Mental Health Trust to respond to in detail, as the warrant application process is
not conducted by the MPS. However, | believe it would assist HM Coroner, by explaining the
processes in place for securing police assistance in such matters.

The Mental Health Act 1983 (Codes of Practice), stipulate that responsibilities for arranging
Mental Health Act Assessments lie with Local Authorities, who must ensure there are sufficient
Approved Mental Health Professionals (AMHP) available to carry out their roles under the Act.
This includes assessing patients to decide whether an application for detention should be
made.

There are a number of elements the AMHP should arrange before a request is made to the
police to conduct a Mental Health Act Assessment (MHAA). A request for police attendance is
organised by the co-ordinating AMHP service submitting a Form 435A (‘Requesting Police
Help with a Mental Health Act Assessment’) via the MPS Secure Forms Portal. Prior to
accessing the form, the AMHP is provided with details of the information required to complete
the form, ensuring sufficient detail is given to assist the MPS with their request. The information
shared by the AMHP within the Form 435A enables the police to complete the necessary risk
assessments and allocate resources. Following an escalation of risk by either the AMHP or
the police, the matter can be escalated for a more urgent response provided by an Emergency
Response Police Team (ERPT). Where the AMHP has season tobélieve that someoneris in
imminent risk of endangering themselves or others, or they have an immediate concern for the
individual’s welfare, they are informed to telephone 999 immediately.

Where an immediate risk has not been identified, the AMHP responds to two triage questions
confirming whether a warrant has been obtained and where the location for the assessment
is. The AMHP is then requested to provide dates for the assessment to take place. The police
from the relevant geographical area will review the request and search police indices for further
information and intelligence about the individual to be assessed, and the location of the
assessment. Within 48 hours of receipt of the request, the MPS will then contact the AMHP
with a decision about police attendance. The assessment date and time is discussed and
agreed with the AMHP depending on the information contained within the risk assessment.
However, itis also dependent on the AMHP ensuring that all other elements are in place which
could impact on the timeliness ar the date of the MHAA. ;

The risk of harm will always be taken into account when assessing and prioritising these cases.

The current MPS policies and procedures governing the framework, operational and tactical
guidance for Police Officers and Staff, were updated in May 2020. The guidance specifically
assists Basic. Command Unit Operations’ Room Staff involved in the preparation and planning
of warrants under section ee ) and 135(2) of the Mental Health Act with responding to AMHP
requests.

In the days leading to Mr Araujo's death his family became aware that he had made an
online purchase of sodium nitrite which was to be delivered to his father’s home.
Despite raising these issues with Camden and Islington NHS Trust, the Metropolitan
Police and employees of the post office there appeared to be no process available to
the family to escalate their concerns to prevent delivery of this package.

The interception of communications (including postal services) is governed, in general terms,
by the Investigatory Powers Act 2016, supported by the Codes of Practice associated with this

In summary, an authority obtained under this Act is only granted by the Secretary of State in
circumstances defined by Code 4.10, and is necessarily limited.to such matters as in the
interests of national security and preventing or detecting serious crime. It is therefore

regrettable that there would be no lawful powers by which the MPS would have been able to
intercept Mr Araujo’s package.

The use of this and other lawful, unregulated substances and suicide kits to complete suicide
is an issue that is being monitored nationally by police forces, the Home Office and the National
Confidential Inquiry into Suicide and Homicide (NCISH). The MPS has direct communication
with the NCISH on a frequent basis. Reducing access to ‘means’ is a key component in the
prevention of suicide. Unfortunately, given the availability and accessibility of many other
potentially effective methods, restricting access is likely to have limited success. Existing
efforts to reduce the propensity of suicide ideation and suicidal behaviours are often preferable.

Additional Information:
The MPS is committed to learning from deaths by suicide.

A dedicated team 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 intends to draw together information on suicide prevention, support
services, risk indicators, contacts and best practice. A draft external Suicide Prevention Policy
is due to be submitted through the MPS’s internal policy development process. The policy will
be accompanied by a toolkit providing easy to access guidance and advice, from signposting
support services to identifying key partners. .

An investigative standards document, which forms part of the toolkit, is under development
and is designed as an easy fo follow ‘key points to consider’ document for police first
responders. This will enhance knowledge and understanding across the entire MPS and build
on the additional guidance that is already used by some teams where death by suicide is
considered higher risk.

The MPS Suicide Prevention Team is committed to improving the training and guidance
available to all officers and staff within the MPS.

In Conclusion

| wish to express my condolences to the family of Mr Araujo. The MPS is committed to
supporting all vulnerable individuals and working with other professionals to assist them in
getting the appropriate help where necessary. The measures described above allow the MPS
to focus on ensuring the appropriate exchange of information takes place to provide the MPS
with a greater awareness of factors indicating a risk of suicide.

| 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

Deputy Assistant Commissioner

Confidential 

Response to Assistant Coroner Irvine’s Prevention of Future Deaths Report dated 29th January 2021 

relating to the death of Thiago Araujo (‘the Report’) 

Introduction  

1.  Royal Mail Group Limited (‘RMG’) operates the UK mail system.  It is the universal service 

provider obligated by law to deliver mail once per day, Monday to Saturday, to every Mainland 

UK postal address.   

2.  The Report refers to the Post Office.  Post Office Limited is a wholly separate legal entity.  

The two companies were separated in  2012 and now operate independently.  Therefore, 

RMG can make no comment on behalf of the Post Office.   

The Inviolability of the Mail  

3.  Section  104  of  the  Postal  Services  Act  2000  (‘PSA’)  states  that  whilst  in  the  course  of 

transmission by post, a letter, packet, parcel or mail bag and/or their contents are immune 

from “examination, seizure or detention as it would have if it were the property of the Crown.”  

Therefore, a postal packet is inviolable whilst it is in the mail system i.e. from the point it is 

posted until it is delivered. 

4. 

It is a criminal offence for a postal operator to intentionally delay or open a postal packet, 

contrary to his duty and without reasonable excuse, in the course of its transmission by post 

(Section 83(1) PSA). 

5. 

It is also an offence for a person, intentionally and without lawful authority, to intercept any 

communication in course of its transmission by post (section 3(1)(a(iii) of the Investigatory 

Powers Act 2016(‘IPA’)).   

6.  Therefore, RMG staff cannot delay, open or otherwise interfere with postal packets unless 

permitted by law. 

Lawful Interception  

7. 

In the circumstances described in the Report, there are only two routes to lawfully intercept 

postal packets after they are posted and before they are delivered.   

1 

 
 
 
 
 
 
 
 
 Confidential 

Option 1 – IPA powers  

8.  The Police can obtain a targeted interception warrant, a mutual assistance warrant or a bulk 

interception warrant pursuant to Section 6(1) of the IPA.  The communication can also be 

intercepted pursuant to Section 44 of IPA:  

(i) 

(ii) 

if the sender and recipient consent, or  

either the sender or the recipient consents and a directed surveillance authority is in 

force pursuant to Part 2 of the Regulation of Investigatory Powers Act 2000.   

RMG is committed to co-operating with the Police and other law enforcement agencies and 

will always provide assistance to them, as far as the law permits. 

9.  RMG will also assist the Police by undertaking a controlled delivery i.e. delivering an item 

with  Police  Officers  in  close  proximity.      This  allows  the  Police  to  enter  the  premises 

immediately after delivery and seize the postal packet using their powers under the Police 

and Criminal Evidence Act 1984.    

Option 2 - RMG’s Terms and Conditions 

10. Section 83(3) of the PSA states that no offence of opening or delaying the mail is committed 

if the opening or delay is done in accordance with the terms and conditions applicable to the 

transmission of the postal packet by post. There are similar provisions within the IPA which 

make  interception,  for  the  purposes  of  the  provision  and  operation  of  the  postal  service, 

lawful.   

11. RMG’s terms and conditions clearly state that certain items cannot be carried through the 

network. 

A 

list 

of 

these 

prohibited 

items 

can 

be 

found 

at 

https://personal.help.royalmail.com/app/answers/detail/a_id/96.   

12. Certain  items  are  restricted  i.e.  they  may be  carried  but only  if  the  sender complies  with 

certain conditions.  Restricted items, such as lithium batteries, paint and kitchen knives will 

only  be  intercepted  if  the  postal  packet  does  not  comply  with  the  conditions  of  carriage 

(usually how they are packaged).   

2 

 
 
 
 
 
 
 
 
 
 
 Confidential 

13. Training  and  written  guidance  is  available  to  RMG  staff  in  relation  to  the  handling  of 

prohibited  and  restricted  items.    RMG  also  operates  a  Security  Helpdesk  which  staff  can 

contact to report any security or safety issue or seek advice.   

14. Where RMG staff receive information, or have cause to suspect, that a postal packet contains 

a prohibited item which is also illegal (such as controlled drugs, automatic firearms or child 

pornography)  the  Police  will  be  contacted  (unless  the  Police  are  the  source  of  the 

information).  The packet will then be opened and inspected by the Police.  The Police will 

assess the legality of the item and will inform the RMG staff of their opinion and any other 

information available.   If the RMG staff member is satisfied the item is illegal, and therefore 

prohibited, it will be handed to the Police.  As above, we will assist the police in performing 

a controlled delivery, if requested.  If RMG staff are unsure of what action to take they can 

always contact the Security Helpdesk for advice.   

15. If RMG staff receive information, or have cause to suspect, that a postal packet contains a 

prohibited item which is not illegal per se (such as flammable gas, pesticides or live animals) 

our  staff may  open  and  inspect  the  contents  to  ascertain  whether  the  item  is  prohibited.  

Where our staff are sure the item is prohibited, RMG has a wide discretion as to the disposal 

of that item thereafter. 

16. However,  our  staff  must be  sure  the  item  is prohibited.   RMG  operates  the  national mail 

system. Our primary purpose is to receive, process and deliver postal packets.  This includes 

handling many items which are not dangerous per se but could be used to cause harm.  The 

purpose to which an item, which is not prohibited, might be put is not a consideration for the 

national postal operator.   We must also be careful not to expose our staff to criminal liability 

by allowing or encouraging them to intercept mail unless it is lawful to do so. 

17. Therefore,  before  any  postal  packet,  suspected  to  contain  prohibited  items  which  are  not 

illegal, is opened, delivery office staff should make contact with the Security Helpdesk for an 

assessment  to  be  made  as  to  whether  interception  is  lawful.  Security  Helpdesk  staff  are 

provided with written guidance and a process to follow to determine the issue and record 

the reasons for the decision made.  If the item is assessed as prohibited, it will be disposed 

of appropriately.    

3 

 
 
 
 
 
 
 
 
 Confidential 

Conclusion  

18. We are satisfied that, within the restrictions placed upon us by law, our processes for the 

handling  of  restricted  and  prohibited  items  within  the  mail  system  are  adequate  and 

appropriate.  Therefore, we do not intend to take any action in response to the Report.   

19. No specific information has been presented establishing that RMG was asked to intercept, 

delay or otherwise divert the postal packet concerned.   If there is evidence that information 

was passed to RMG staff and no action was taken, we would be grateful to receive details of 

what information was passed to our staff and in what circumstances.  We will then conduct 

further enquires. 

Senior Legal Advisor  

Royal Mail Legal 

12th March 2021 

4

INHS}

Camden and Islington
NHS Foundation Trust

Executive Office

4" Floor, East Wing

St Pancras Hospital

4 St Pancras Way

London NW1 OPE
Tel:

www.candi.nhs.uk

26" March 2021
Private and Confidential
Coroner Graeme Irvine
Inner North London
Poplar Coroner's Court
127 Poplar High Street
London £14 OAE

Dear Coroner Irvine

Re: Inquest into the death of Thiago Araujo — Prevention of Future Deaths report

| am writing further to the inquest for Thiago Araujo which was heard on 4% — 6* January
2021 and concluded on Thursday 28" January. Following the inquest you issued a
Prevention of Future Deaths report to a number of organisations including the Trust. | will
address the matters of concern raised in this report in turn.

On 24" January 2020 Mr Araujo had discharged himself from psychiatric inpatient care; he
was to be supervised by the Camden and Islington NHS Foundation Trust crisis team. Mr
Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the
crisis team closed Mr Araujo’s referral. in the course of this closure no arrangements were
made to address the risks presented by Mr Araujo.

Following the initial 3 days of this inquest the Trust wrote to you to provide some additional
assurance around the Serious Incident (SI) investigation report and the recommendations
made, which were updated and strengthened in light of the issues raised at the hearing.
One of the additional recommendations concerned this matter and is as follows

Additional Recommendation: Any service user of the Crisis Team who is being considered
for discharge because of non-engagement must be discussed in the Crisis Service Multi-
Disciplinary Meeting with senior overview of the decision to discharge. The decision and
rationale to discharge because of non-engagement must be clearly communicated to the

Your partner in CRI
care & improvement

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NHS

community team and carers and this must be clearly documented in the clinical notes. When
a service user is discharged because of non-engagement the Community Team must update
the Crisis and Contingency Plans to ensure the service user and carers are aware of the
support available following discharge.

This action was due to be completed by the end of February and | can confirm that this
practice is now in place.

. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis
team was not permanent, and had Mr Araujo or his family approached the crisis team to
reopen his case, steps could have been taken to reinstate crisis team support. Mr Araujo’s
family were unaware of this facility.

On discharge it is the crisis team’s standard practice to advise service users that they may re-
refer themselves, or be re-referred, should the need arise. We can only sincerely apologise
to Mr Araujo’s family if this was not made clear to them in this case. All crisis team staff
have been reminded of the need to ensure that this information plus relevant contact details
is passed on. This is also covered by the recommendation at point 1, where the updating of
crisis and contingency plans is required.

. Families and carers of patients diagnosed with emotionally unstable personality disorder do
not receive support or education upon management of this diagnosis from Camden and
Islington NHS Foundation Trust, unless the patient has been received for treatment by the
personality disorder service.

The Trust has a duty to assess carers need for support as part of its responsibilities under the
Section 75 Agreement with the Local Authority. When the Personality Disorder Service
identify a carer who may be in need of support, either at the point of referral, assessment or
during the treatment of a patient, a Carers Assessment at the service is offered. A Carers
Lead is employed to fulfil this role. When the Personality Disorder Service is not directly
involved carers are directed to Local Authority services - Support for carers | Camden &
Islington Carers Hub | Supporting unpaid carers in Islington. Carers assessments are also
carried out by other community teams within the Trust, including the community rehab
team, who can support carers to access appropriate support. The Trust recognised that a
key theme in the report was that carers had lost confidence in the teams working with the
deceased and did not feel their views were taken on board. As a result of this feedback the
Trust has revised the action plan with an additional recommendation relevant to carers
involvement. To provide assurance that this is consistently happening, the strengthened
action plan includes a requirement for community teams to carry out 6 monthly audits,
checking that carers are routinely offered an assessment and support plan, and that
information, support and psychoeducation are available. Plans will be developed to address
any gaps identified as a result of these audits which are now underway within the teams.

NHS

4. By 4 February 2020 the Camden and Islington Recovery Team identified an acute risk of
suicide in Mr Araujo, faced with his noncompliance with community treatment they
considered an admission into inpatient care. No actions were taken to affect this plan.

In evidence the community recovery team indicated that a factor in their inaction was the
knowledge that arranging a section 135 Mental Health Act 1983 warrant and assessment
would take two weeks. Such an assessment requires actions from an approved mental
doctors, the assistance of the Metropolitan police and the local magistrates court to secure a
warrant. A delay of 14 days in securing a Mental Health Act assessment is in my view
unacceptable.

The AMHP service, which coordinates and carries out assessments under the Mental Health
Act, is a local authority service, although physically based on Trust premises. The Trust has
liaised with our local authority partners in regard to this important issue and we can report
as follows:

The average wait for a community assessment at the moment is around 14 days. In
February 2020 when the incident took place the average wait time was closer to 18 days, so
we are seeing some improvement but acknowledge further is required. This issue is part of
our CQC action plan and ongoing monitoring is in place as part of this via our Mental Health
Law Committee.

Reducing average time

There have been a number of actions by the AMHP service and the police to reduce wait
time over the last year. Very often delays have been due to police availability/capacity in
regard to providing a time slot when they are able to attend in support of an assessment.
The police now have a permanent team in their mental health department and the size of
this team has been maintained. They also have a more robust management structure so we
have a clear reporting mechanism if we have concerns. This has enabled the team to
continue to support us throughout the year.

The AMHP team is responsive to the challenges of the Covid 19 pandemic, including the
management of staff absence, to ensure all resources across the boroughs are used to
maximum effectiveness and response to service user needs.

In mid-2020 both boroughs made additional investment in their staffing.

Prioritisati
Although the average wait time for a community assessment is 14 days, response is
managed with individual risk assessment and prioritised response. At the point of referral
for a Mental Health Act assessment the referral is discussed with the referrer and an
understanding of the risks and urgency of the assessment are established. Any assessments

INHS

with significant risks are flagged to the duty manager and service manager and an early
conversation is had with the police. It is established practice to communicate with the
referrer so that the AMHP team are aware of and can respond to changes in the service
user's level of assessed risk.

The inquest has highlighted the need to ensure Trust services are aware of the AMHP
service's capacity to prioritise waiting times and the AMHP service's commitment to ongoing
information sharing with referrers.

. In the days leading to Mr Araujo’s death his family became aware that he had made an
online purchase of sodium nitrite which was to be delivered to his father’s home. Despite
raising these issues with Camden and Islington NHS Trust, the Metropolitan police and
employees of the Post Office there appeared to be no process available to the family to
escalate their concerns to prevent delivery of this package.

It was apparent from the evidence given at the inquest that at the time of this incident Trust
staff were unsure how to respond to this situation and what actions if any were available to
them. The Trust has since sought advice from its legal team and guidance to staff on this
issue, as well as reiteration of previous advice around access to means to self-harm
generally, has been circulated across the organisation.

The legal advice we have received is that the Royal Mail do potentially have powers to
intercept and destroy packages containing items which are either prohibited or restricted
from being sent in the mail. Therefore, as part of the response to concerns of this nature,
teams should consider reporting any concerns about potentially dangerous packages to the
Royal Mail (via the local sorting office) and also to the police and must ensure that
discussions and actions taken are documented in the clinical records.

It would be very helpful in informing our actions going forward, if we can be provided witha
copy of the Royal Mail's response to the PFD as we are keen to work with them in regard to
these challenging situations.

| hope that my response clarifies the position and provides you with the necessary
reassurance. If you need any further information, please do not hesitate to contact me.

Yours sincerely