Narjit Gill

Deborah R Lakin 
Assistant Coroner  
The Justice Centre,  
Newbold Terrace,  
Leamington Spa  
CV32 4EL 

2 April 2024 

Dear Ms Lakin,  

Re: The late Mr Narjit Gill  

I am writing to you in response to the Regulation 28: Prevention of Future Deaths Report 
which  was  received  from  your  office  on  9  February  2024,  which  followed  the  inquest 
conducted in respect of the death of Mr Narjit Gill. 

In concluding the inquest, you raised a concern that there was a “Failure to remove the 
 from the tree in Mr Gill’s garden when it was seen on 3 May 2023 
ladder 
by mental health practitioners who visited Mr Gill at his home, in light of his continued 
expression of suicidal ideation.”  

Working  with  my  executive  colleagues  and  with  clinicians  and  service  leads,  we  have 
given full and serious thought to our response to the concern that you have raised. 

I  understand  your  inquest  received  and  heard  evidence  in  respect  of  the  care  and 
treatment that was provided to Mr Gill, including in the immediate days prior to his death.  
Clinicians had been in contact and had visited Mr Gill at his home address and had also 
spoken with Mr Gill on the telephone. Clinicians were supporting Mr Gill to manage his 
mental health and wellbeing, taking a person-centred approach to his needs at the time 
and a  least  restrictive option.  Although  Mr Gill had  reported attempts  to harm  himself, 
however  he  had  also  identified  protective  factors  in  place  that  were  focussed  on  the 
impact of his death on those close to him.  He had been in recent contact with his friend 
and was future orientated in wanting to find purpose through employment and resolving 
a housing issue. 

Our internal learning review following his death did not identify systemic failures in care, 
but had identified some learning points, which focussed on ensuring staff understanding 
of internal referral processes to support safe transition between services; documenting 
important events and ensuring that pertinent detail is captured in health records, including 
recording of a rationale when assessment for capacity is recorded. 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100  
www.covwarkpt.nhs.uk 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  thinking  through  our  response,  I  wanted  to  ensure  that  I  contextualised  the 
circumstances  that  community-based  clinicians  work  in,  when  supporting  people  with 
often complex needs and social circumstances. 

A person who receives care in the community is deemed to be able to make decisions 
about their own safety.  The review of Mr Gill’s care and treatment had identified that he 
was not detainable under the Mental Health Act, and he did not require a mental health 
act assessment at that time.  We are required to treat all patients in the least restrictive 
manner, and this would include where we would be “required to take immediate control 
of a dangerous situation where there is a real possibility of harm to the person or others 
if no action is undertaken”, and “to end or reduce significantly the danger to the patient 
or others”1.  At the time of Mr Gill’s assessment (3 May 2023) he was deemed able to 
manage himself safely with continued input from community mental health services. He 
was not deemed to be in imminent danger, and this was borne out in the discussion with 
the clinician later the same evening. 

A person admitted to an inpatient mental health ward, would have presented with clinical 
risks that the service and the individual cannot manage safely in the community.  Within 
our inpatient areas, it is our responsibility to ensure that objects either belonging to the 
Trust or part of the fabric of the building and environment are not able to cause patient 
harm or indeed be used by a patient to self-harm. Depending on individual clinical risks, 
it is also our responsibility to restrict or remove items and property belonging to a patient 
if they or others could use it to cause harm. Examples of these would be mobile phone 
charging  leads,  and  cigarette  lighters.  With  the  exception  of  offensive  weapons,  all 
property would be returned to the patient during periods of leave, or at discharge. 

The decision making required of staff, and their ability to act, is different in the community 
setting, whereby a person receiving mental health care and treatment is also surrounded 
by objects commonly found in home settings that can be used to harm themselves (e.g 
power leads,  ignition  sources,  knives,  scarves  and  belts, or items that  can  be  used to 
gain height such as a ladder, chair or footstool).  Whilst we would expect clinicians to talk 
with an individual about self harming behaviour, the property belongs to the patient and 
staff would not have an automatic right to take that property from them.   

There  are  other  avenues  of  support  and  actions  available  to  staff,  should  they  be 
concerned about a patient’s capacity to make decisions.  For example, if a patient had 
an offensive weapon, it would be pertinent to call the police to support that item being 
removed.    Or,  if  a  patient  was  seen  to  be  hoarding  prescribed  medication,  that  the 
prescription be reduced/minimised and perhaps the person required to attend a named 
venue to receive and consume medication on site.   

All approaches to safe risk assessment involve engaging with the patient to understand 
their current capacity, their risk behaviours and their ability to keep themselves safe in a 

1 https://www.rcpsych.ac.uk/improving-care/nccmh/quality-improvement-programmes/MHSIP-reducing-
restrictive-practice/reducing-restrictive-practice/about-this-collaborative 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100  
www.covwarkpt.nhs.uk 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 person-centred  way.    We  will  continue  to  support  clinicians  to  undertake  dynamic  risk 
assessments approach while supporting people to receive care and treatment in the least 
restrictive way, making sure that inpatient admission is appropriate to a person’s needs, 
exploration  and  consideration  of  other  initiatives  and  alternatives  to  admission  and 
supporting people to remain within their local communities. 

Whilst we cannot advocate for the removal of patient property from their possession in a 
practical manner, including where removal of objects from height may present a safety 
risk to staff, we do agree that there is an opportunity to continue our improvement journey 
and learn from Mr Gill’s death.   

As  part  of  our  ongoing  improvement  work,  we  have  recently  updated  our  information 
packs focussed on ‘Suicide Prevention:  Red Flags”.  This work is presented as a poster 
and a screen saver and highlights significant events which can contribute to a change in 
a person’s needs.  The React, Engage, Discuss (RED) flags cover emotional, physical, 
relationship, financial and social factors as well as drawing attention to risk assessment 
and helpful phone numbers.  

After  successfully  recruiting  to  the  key  post  of  “Lead  For  Clinical  Risk  and  Suicide 
Prevention” we have been able to recommence our internal Risk Assessment Training.  
the training which comprises of a 4 hour session targeted at clinicians and provides staff 
the  tools  and  knowledge  to  conduct  a  comprehensive  risk  assessment.  The  training 
focuses on current and historical risk, positive risk taking and personal safety plans. 

We are also:  

•  Continuing  our  work  to  implement  the  NICE  Guideline  “Self  Harm:  Assessment  
management and preventing recurrence”, which was published in September 2022.  
The guideline sets out an important and systemic change in the way that we currently 
approach  risk  assessment,  in  that  it  deliberately  moves  away  from  using  risk 
assessment tools and scales (e.g. low, medium or high) to determine who should or 
who should not be offered treatment. Implementing the guideline will support clinicians 
to ‘Risk Formulate’ and focus the co-produced assessment on the person's needs and 
how to support their immediate and long-term psychological and physical safety. 
•  Continue  to  engage  with  external  national  bodies  to  access  training  to  support 
embedding  of  the  co-produce  standardised  approaches  to  risk  based  training  in 
respect of the implementation of the NICE Guidance. 

I have set out what I believe is a focussed response to the issue you have raised with 
me, but please contact me if you have any additional questions, that I can assist you with.   

I would be grateful if you would share a copy of my response with Mr Gill’s sister, 

, and with the Chief Constable of Warwickshire Police. 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100  
www.covwarkpt.nhs.uk 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely  

Chief Executive Officer 

Copy to: 

, Chief Nursing Officer / Deputy Chief Executive  

, Chief Medical Officer   

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100  
www.covwarkpt.nhs.uk

From Maria Caulfield MP   
Parliamentary Under-Secretary of State for   
Mental Health and Women's Health Strategy 

39 Victoria Street 
London 
SW1H 0EU 

Deborah Rachel Lakin 
Assistant Coroner  
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
CV32 4EL 

Dear Mrs Lakin, 

24 May 2024 

Thank you for the Regulation 28 report to prevent future deaths of 9 February 2024 about 
the death of Narjit Gill. I am replying as Minister with responsibility for mental health.   

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Mr  Gill’s 
death, and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my  attention.  Thank  you  for  the  additional  time  provided  to  the  department  to  provide  a 
response to the concern raised in the report. 

The report raises concerns over the failure to remove the ladder and/or noose from the tree 
in  Mr  Gill’s  garden  when  it  was  seen  on  3  May  2023  by  mental health  practitioners  who 
visited Mr Gill at his home, in light of his continued expression of suicidal ideation. 

In preparing this response, Departmental officials have made enquiries with NHS England. 

The  matters  of  concern  raised  are  primarily  for  the  Trust  to  address,  and  I  note  that  the 
Coventry and Warwickshire NHS Partnership Trust (CWPT) has addressed your concern 
in detail in their  response.  CWPT  has  identified  learning  points  in  their  internal  learning 
review  and have  advised  that  they  have  recently  updated  information  packs  focussed 
on  ‘Suicide  Prevention:  Red  Flags”  and  recommenced  their  internal  Risk  Assessment 
Training.  

 
 
 
 It is vital that lessons are learnt collectively, and changes are made to reflect where things 
have gone wrong, which is essential to ensure the NHS provides safe, high-quality care. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Yours sincerely, 

MARIA CAULFIELD MP

Dear Ms Lakin 

Report to Prevent Future Deaths – Narjit GILL  

We confirm receipt of your PFD Report dated 9 February 2024 following the conclusion of the 
Inquest into the death of Mr Gill on 5 May 2023. 

Having  reviewed  our  records  in  this  matter,  we  can  see  that  Warwickshire  Police  officers 
attended Mr Gill’s home address on two occasions prior to his death, namely on 24 April 2023 
and 25 April 2023.  On each occasion, officers spoke with Mr Gill, attended with mental health 
professionals  and/or  liaised  with  them  appropriately  and  on  each  occasion  confirmed  that 
Mental Health were engaged with him. 

On our first attendance, officers were accompanied by a mental health nurse.  It was confirmed 
that  Mr  Gill  had  capacity  and  that  his  attempt  to  harm  himself  appeared  to  be  an  isolated 
incident.  It was left that mental health services were engaged with him. 

On the second attendance, it was confirmed that Mr Gill had been referred to mental health 
services  and  continued  to  have  capacity.    He  declined  to  go  to  hospital  or  be  seen  by  the 
ambulance service.  Officers liaised with mental health services again and it was confirmed 
that the Access Hub had been in contact with Mr Gill by telephone earlier.  He had advised 
them that he had reflected and did not want to die.   

As a result of the further attendance of police officers, the Access Hub were contacted again 
but  refused  to  attend  and  further  refused  to  make  contact  again  with  Mr  Gill  by  telephone.  
They were advised that officers had correctly identified that they had no powers to act under 
section 136 of the Mental Health Act as Mr Gill was in his own home, and therefore a Mental 
Health Act assessment was requested, and the Access Hub agreed to attempt to contact the 
on-call AMHP.  When police advised, they would need to leave Mr Gill’s property as they had 
no powers and could do no more, the Access Hub agreed that a manager would review the 
case and take ownership. 

The attending officer completed a Vulnerable Adult referral at 03.29am on 26 April, confirming 
the details of their attendance and that the matter had been left with mental health services as 
the most appropriate authority to support Mr Gill. 

Thereafter Warwickshire Police had no further involvement with Mr Gill prior to his death. 

Therefore, we note the contents of the PFD report but we are of the view that the concerns 
raised are not for our Force in this case, as our officers appropriately engaged with Mental 
Health Services and made appropriately referrals throughout. 

Yours sincerely 

Chief Constable 

Warwickshire Police