Prevention of Future Deaths reports · 2021

Levi Petitt

Regulation 28 report to prevent future deaths, reference 2021-0231, written 6 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Jul 2021
Reference2021-0231
DeceasedLevi Petitt
CoronerPaul Cooper
Coroner areaLincolnshire
CategoryPolice related deaths · Suicide (from 2015) · Mental Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

«AuthorisingUserFullName»
«AuthorisingUserAppointment»
County of Lincolnshire

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. The Chief Constable of Lincolnshire
2,

CORONER

| am Paul Cooper, Assistant Coroner for the Coroner area of Lincolnshire, 4 Lindum Road, Lincoln,
Lincolnshire, LN2 1NN.

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 1 09/01/2020 | commenced an investigation into the death of Levi Craig Don Petitt, aged 19 on
23" December 2019 . The investigation concluded at the end of the inquest on 30™ June 2021. The
conclusion of the inquest was that Levi died as a result of Suicide, the medical cause of death
being:

la. Asphyxia
1b. Hanging
1c;

2;

CIRCUMSTANCES OF THE DEATH

1.A 999 report was received on 8" December 2019 by Lincolnshire police that Levi had suicidal
ideations

2.Pc i located Levi ,spoke to him and made sure he was safe before departure referring him
to agencies that could assist relying upon Levi to take the initiative.

3.PC RE dia not refer by PNN, complete a mental health proforma or refer the matter to
anyone else in authority

ed eh accepted he thought Levi would follow up on his referrals and used his
discretion on the night.

5.The family disagreed on medical grounds.

6.4 days later Levi committed suicide.

CORONER’S CONCERNS

«AuthorisingUserFullName»
«AuthorisingUserAppointment»
County of Lincolnshire

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. —

l) PC was not aware of the Lincolnshire Police Concern for Welfare Policy
Document PD238

Il) PCM edmitted he used his discretion in dealing with the deceased and did not make a
PNN ,complete a mental welfare proforma report, or reported the incident to any other officer
on the night

KIIl) DA nen asked did not know what happened to the mental health proforma when
completed

IV) Procedures appear to be in place to deal with such incidents. Please explain what training
your officers receive to deal with such circumstances and are you satisfied your officers are
sufficiently aware of the said policy document and act upon it.

(IV)

(Vv)

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your organisation has
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, namely by
16/12/2020. |, 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons

(a Lincolnshire Police
(b

lam 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.

Date: «AuthorisedDateShort»

AGE

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«AuthorisingUserAppointment»
of Lincolnshire

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Responses

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.

Response from Lincolnshire Police (PDF)
19 August 2021 

Mr Paul Cooper 
Assistant Coroner 
4 Lindum Road 
Lincoln 
LN2 1NN 

Dear Mr Cooper 

Regulation 28 LCDP 

I am writing to formally reply to your direction for Lincolnshire Police to respond to a Regulation 28 
Notice made by you with regards to Mr Levi Pettit. 

I offer my condolences to the family and friends of Levi in what was a very sad and tragic case. 

I asked my Assistant Chief Constable for Local Policing, 
 to review our current approach 
and training.   He is the strategic lead for Mental Health policing for Lincolnshire Police, the regional 
strategic lead for Mental Health policing, and a former member of the HMICFRS working group on 
Mental Health policing. 

Lincolnshire Police’s response is set out below under the key matters you raise as a concern. 

1. PC 

 was not aware of the Lincolnshire Police Concern for Welfare Policy

Document PD238

I am in agreement with you that PC 
 “…did act appropriately” and, “…went the extra mile” 
with regards to his actions on the evening with Levi.  I would not expect frontline officers to know 
the detail, nor even the existence of a “Concern for Welfare Policy”.  The Policy is designed to 
document our approach to calls for service through the Force Control Room, rather than as guidance 
for frontline officers.  You will note that Document PD238 was written by Force Control Room (FCR) 
Inspector 
and ethically compliant.  It is not a guidance document for frontline officers. 

 and is annually reviewed by the FCR inspector to ensure that it is still legislatively 

Continued…

Chief Constable 
Lincolnshire Police 
Chief Constable’s Office 
Police Headquarters 
PO Box 999 
Lincoln LN5 7PH 
(Sat Nav: LN2 2LT) 
www.lincs.police.uk  

 
 
 
 2 

19 August 2021 

Mr Paul Cooper 

It is expected that officers will be sent to incidents of this nature by the FCR, and that under those 
circumstances the officers can be expected to operate in line with their training and the various 
materials and support mechanisms available to them in order to make sound, ethical and lawful 
decisions.  

More detail on this will be found in the answer to concern number 4. 

To reassure ourselves that our guidance to officers and staff in the FCR is being adhered to, I have 
ensured that the relevant policy document is recirculated among our FCR staff, and informs our 
decision making process when receiving, allocating, reviewing and closing incidents of this nature. 

2.  PC 

admitted he used his discretion in dealing with the deceased and did not make a 

PPN, complete a mental health proforma report, or report the incident to any other officer 
that night. 

 to have used his discretion in dealing with Levi.  In the circumstances, my 

I would expect PC 
understanding is the officer dealt with Levi as he felt necessary, and having reviewed his action on 
the night I believe he was right to do so.  Levi was not presenting in such a manner as to justify a 
 did actually report the 
detention under section 136 of the Mental Health Act 1983.   PC 
incident by updating it onto the Force Command and Control system.   All reported incidents 
attended are updated by the officer and are ultimately overseen by the FCR Inspectors who cover 
that time period.   I am satisfied that there was appropriate oversight of PC 
evening. 

’s actions on the 

Based on the nature of PC 
’s observations on the evening, the recording of his operational 
dealings on the incident and the discourse with Levi on the night, I agree with the observation that 
PC 
discretion not to raise a PPN. 

 did “act appropriately on the night” and “went the extra mile”, and that he exercised his 

As mentioned in my answer to question 1, above, I will ensure that the relevant guidance is 
recirculated to officers and staff in the FCR to remind them of the importance of the relevant policies 
in place. 

3.  DS 

 did not know what happened to the mental health proforma when completed. 

 to know what happens to the mental health proforma once 

I would not expect DS 
completed. Officers are trained (see below) to understand that the mental health proforma provides 
a statistical return that is used by the Home Office and other stakeholders to understand the local 
data for mental health policing. It is not a referral mechanism. We do have an administrator who 
checks against our incidents to ensure that mental health proforma have been completed when 
required. Understanding the mechanics of the workflow of this statistical submission would not 
contribute to officers’ work “on the ground”. 

Continued… 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 

19 August 2021 

Mr Paul Cooper 

The mental health proforma has no bearing on the care or practice of officers given on the ground, 
and while officers are trained to understand why, when and how to submit a mental health 
proforma, it is not necessary for them to understand the mechanics of the data collection element of 
the process.   I do not therefore believe that further training on this matter is proportionate or 
would help prevent further adverse incidents. 

4.  Procedures appear to be in place to deal with such incidents.  Please explain what training 

your officers receive to deal with such circumstances, and are you satisfied your officers are 
sufficiently aware of the said policy document and act upon it? 

Our training for mental health incidents begins when an officer undergoes initial training, in what is 
called their “student officer phase”, i.e. their first two years of policing practice. 

This basic training involves modules on: 

•  Understanding how to deal with issues of vulnerability when attending the scene of an 

incident as a first responder. (Explaining the Importance of recognising vulnerability when 
attending incidents, understanding the procedures for dealing with vulnerable people) 
•  Applying practical policing skills when attending an incident as a first responder. (Explaining 
and practicing specific considerations for responding to common high- risk incidents) 
•  Personal protection skills. (Including the Police use of restraint in mental health & learning 

disability settings) 

•  Explaining the national drivers for the police service in providing a professional and ethical 
service to individuals who are, or may be, vulnerable, have suffered harm or be at risk of 
harm. (Special reference to Mental Health ACT 1983 and Capacity Act 2005) 

•  Explaining the personal aspect of vulnerability. (Discussing personal vulnerabilities, when 
combined with situational/environmental factors, that can result in harm or risk of harm). 
•  Explain key considerations when responding to, identifying and supporting a person who 
may be vulnerable. (Applying the principle of dealing with a person without judgement, 
fairly and in a manner appropriate to their needs). 

•  Taking appropriate initial action when dealing with a person who is, or may be, vulnerable. 

(Practical application of the Capacity Act 2005 and Mental Health Act 1983) 

It is important to remember that police officers are not mental health professionals.   This was 
recognised in the HMICFRS 2018 publication - Policing Mental Health: Picking up the Pieces - which 
said: 

“…our inspection found that, in dealing with people with mental health problems, police 
officers and staff must do complex and high-risk work.  They often don’t have the skills they 
need to support people with mental health problems.   And, too often, they find themselves 
responsible for the safety and welfare of people that other professionals would be better 
placed to deal with.”  (p.4) 

Continued… 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

19 August 2021 

Mr Paul Cooper 

To supplement our extensive initial training, our officers do receive formal training in mental health 
legislation and further training in “Mental Health First Aid”, which is delivered using accredited 
Mental Health First Aid (MHFA) trainers and in accordance with the national standards.    Further 
information on the course can be found at https://mhfaengland.org/.   This training is over and 
above the standard training which is available to many forces in England and Wales and it involves 
an in-depth understanding of the complex legislation and awareness of common mental health 
conditions. 

To support this work, the force now also has access to: 

•  A 24/7 phone line with access to a trained mental health professional to give immediate 

advice 

•  A full set of guides for officers on mental health.  This is accessible via their mobile data 

terminals.   A copy is attached for your information. 

•  Regular briefings via the force intranet and vlogs. 
•  Trained mental health workers available in the FCR to give immediate advice and triage to 

officers on the ground dealing with mental health related incidents. 

I am satisfied that our procedures, training and support provide our officers with the best possible 
opportunity to positively intervene and ensure that we take opportunities to ensure help is available 
to individuals presenting with mental ill health.  

This training and activity supports my vision and strategic objective of “Helping those in need”.   Our 
work on mental health policing has also been a key strand in supporting the plans of the Police and 
. 
Crime Commissioner for Lincolnshire, 

In order to make such a statement, ACC 
Between 00:01 on the 14th of August 2021 and 23:59 on the 15th of August 2021, there were 115 
incidents created on our system as “Concerns for Welfare”.   A great many of these contained 
apparent incidents of mental ill health or concerns that a person was at risk of causing themselves 
harm.   All of those incidents were dealt with in accordance with our policy, and in line with our 
training and values. 

 has carried out a dip-sample our work in this area.   

We are also engaged with the health community to ensure that the health sector is commissioned in 
such a way as to have sufficient capacity to reach patients in need rather than relying on the police 
service to provide emergency mental health coverage.   We have been very proactive in trying to 
ensure that we, as a service, provide what we can in terms of addressing those individuals in need of 
health intervention when we work with them.  

Yours sincerely 

Chief Constable

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