Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0522, written 29 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2024 |
|---|---|
| Reference | 2024-0522 |
| Deceased | Leighton Dickens |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Police related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Constable of South Wales Police
1 CORONER
I am David Regan, Assistant Coroner, for the coroner area of South Wales
Central.
2 CORONER’S LEGAL POWERS
I 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.
3
INVESTIGATION and INQUEST
A Coronial investigation was commenced on 27th October 2020 into the death
of Leighton Alan Dickens. The Investigation concluded at the end of the
inquest which I conducted with a jury on 18th – 28th September 2023. The
conclusion was a narrative conclusion and the medical cause of death was 1 (a)
pressure on the neck (incomplete or atypical hanging)
4 CIRCUMSTANCES OF THE DEATH
These were recorded as: -
Leighton Dickens died by incomplete atypical hanging alone in his home
address on 14th October 2020.
The narrative conclusion which the Jury returned was:
Leighton Dickens died by hanging himself in circumstances where his
intention could not be ascertained. It is the juries understanding, that it was a
1
missed opportunity on the part of the police not to detain Leighton Dickens at
hospital until he had been assessed by a Mental Health Professional.
The Inquest focused upon: -
a. Mr Dickens’ mental health condition and behaviour on the night of his
death.
b. The fact that police officers came upon him by the side of the road in
an undressed state in the presence of his partner who was trying to
convey him to hospital.
c. His presentation and behaviour towards the officers before during and
after arrival at hospital
d. The decision by officers not to invoke their powers under s. 136 Mental
Health Act and to leave Mr Dickens at hospital in circumstances in
which they knew that he had not been subject to medical assessment
and intended to leave.
e. The limited sources of support available to assist or guide the officers.
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. –
(1) Following the withdrawal of the mental health triage support provided
to the police by mental health nurses, the medically qualified sources of
urgent support available to police officers to assist them to safeguard
the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own
case load.
(3) The alternative support available from a mental health tactical adviser,
is not provided by a clinically qualified member of staff and does not
have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to
have been by the “111 press 2” service. This has not been put in to
place and there is no current timescale for it to be put into place.
2
(5) This leaves officers with limited sources of qualified mental health
advice, with access to relevant clinical records, when responding to the
risks posed by those suffering from mental health crisis within the
community
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
you and your organisation 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 24th November 2023. 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 family who may find it useful or of interest.
Welsh Government, Medical Director of the Cwm Taf Morgannwg University
Health Board, Medical Director of the Cardiff and Vale University Health
Board, Medical Director of the Swansea Bay University Health Board.
I 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.
9
29th September 2023 SIGNED:
D Regan
Assistant Coroner
3
4
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.
Pencadlys Heddlu | Police Headquarters
HeolyBonttaen | Cowbridge Road
Penybort Bridgend
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www. heddiu-de-cymru.police.uk www.south-wales.potica.uk
Reference: nnn
To: Mr D Regan
HM Assistant Coroner
ey eri! to
Coroner's Officer
Dear Mr Regan,
Re: Regulation 28 Report to Prevent Future Deaths
inquest Into the Death of Leighton Alan Dickens
| write on behalf of the Chief Constable of South Wales Police in response to the Prevention
of Future Deaths Report issued on the 29th September 2023 following the conclusion of the
inquest into the death of Leighton Alan Dickens who tragically died on the 14th October
2020.
{ have carefully considered the entirety of the report and wish to reiterate that as an
organisation we continue to take seriously the need to meaningfully reflect on the evidence
heard during Mr Dickens inquest. We are committed to ensuring the duty of care shown by
our officers to the individual concerned is always paramount and welcome any findings and
recommendations to ensure the highest standards of service are maintained.
This response will be focused on the points raised in section S of the Preventing Future
Deaths Report, and | will address each concern in turn as set out below:
(1) Following the withdrawal of the mental health triage support provided to the police
by mental health nurses, the medically qualified sources of urgent support available to
police officers to assist them to safeguard the public are limited to the mental health crisis
teams.
The previous Mental Health Triage scheme provided a contact for medically qualified advice
based in the police control room on which police decision makers and front-line officers
would be able to use to assist real-time urgent decisions on mental health related incidents.
Moe Hedctu De Cymru yn croesowy derbyn goheblaeth
yn Gyrvacg e Seesneg, sieb goheblouths
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yriereran a
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However, this advice was available during a core set of hours based on demand profiling,
which was 09:00 until 01:00 hours. As such it would not have been available to the
attending officers in this matter.
The scheme did not extend to providing legislative advice on the Mental Health Act or other
applicable legislation such as the Mental Capacity Act.
On withdrawal of the service, discussions did take place between senior leaders in both
Health service and South Wales Police to manage the arrangements for the provision of
advice.
Since the withdrawal of the service, the South Wales Police ‘Mental Health - Section 136’
policy has been updated. The Policy defines the treatment of people by South Wales Police
officers under the Mental Health Act 1983. The policy also provides guidance to officers, and
staff in the management of mental health concerns, and on the partnership arrangements
in responding to mental health related incidents.
Policy section 1.2 (Mental Health — Section 136) defines the specific requirement for police
to seek advice from a health professional who are maintained on an agreed list, before
detaining a person under s136 of the Mental Health Act. The policy outlines both the
legislative and practical considerations in obtaining advice for use in decision making on
$136. Within this section of the policy, it contains the contact details for each crisis team in
the respective health board area should urgent advice be required.
Following the withdrawal of mental health triage support there remains a dedicated
pathway for police officers and staff to obtain urgent (24-hour) medically qualified advice to
inform police decision making on the use of s136. This does satisfy the requirements for
advice to be obtained as outlined by the Mental Health Act Codes of Practice.
‘When deciding that detention may be necessary, the police may also benefit from
seeking advice before using section 136 powers in cases where they are unsure
that the circumstances are sufficiently serious for using these powers. Local
protocols should set out how this advice can be provided and who the police
should contact, including outside of normal business hours.’
(Mental Health Act Codes of Practice 16.23)
Mae Heddlu De Oymmu yn crostawu derbyn gohebiseth
‘yn Gymraeg a Saesneg, Byddiwn yn ateb gohebaeth a
derbyrru: yn Gymnreeg yn Gyeruneg ac nifyld gohebu yn
(Gytivaag yn arwain a1 oad.
South Wales Police welcomes receiving correspondence
in Welh and Engish. Any conespondance received in
‘Welsh vil be answered in Welsh and corresponding in
‘Weish will not feed to a delay in responding.
south-wales.police.uk €}()@ swpolice HeddiuDeCymru
POLICE
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In response to this Regulation 28 report, extensive force communications have been
published which reinforces the arrangements for seeking urgent medically qualified advice
prior the use of powers under s136. These included formal communications via Weekly
Orders, signposting on intranet and follow up by our Mental Health liaison Officers. This
communication also highlights additional points of learning as a result of issues arising in
this case.
South Wales Police employs 3 dedicated Mental Health Liaison Officers (MHLO’s) and a
Strategic Force Mental Health Advisor, who as part of their responsibilities engage with
responding officers, educate on approved practice, identify areas for improvement and
escalate concerns both internally and with partners.
(2) The crisis teams may not be readily available and deal with their own case load.
Whilst | cannot provide specific comment on behalf of the Health Board on the capacity of
their Crisis Teams, | can provide assurance that the concerns within the regulation 28
notice have been raised directly with! Director of Operations, Mental
Health Clinical Board.
Formal arrangements for the provision of advice to police by crisis teams are contained
within existing protocols between South Wales Police and the respective Health Boards.
As a result of the Regulation 28 Notice, the accessibility of these crisis lines is monitored
daily by the force Public Protection Department to identify adverse incidents and
accessibility. Information pertaining to the use of $136 powers is also scrutinised in internal
strategic boards and partnership forums, such as the Mental Health Act Monitoring Group.
This monitoring is supported by governance and routes of escalation which include the
Welsh Chief Officers Group on Mental Health, with Senior Responsible Officers attending
from NHS Wales, WAST, Welsh Government and others. The meeting is chaired by the
Assistant Chief Constable Jason Davies and provides an opportunity to escalate concerns.
The Purpose of the group as agreed in the Terms of Reference include:
Mae Heddtu Oe Cymru yn crogsewu derbyn guhebeeth,
yn Gymraeg a Saesneg. By Scten yn ateb gohebaeth a
ddorbynnir yn Gymraeg yn Gymraeg a¢ rs fydd gohebu yn
Gyrrvacg yn arwain at ood:
‘South Wales Police welcomes recelving correspondence
In Welsh and English. Any correspondance receivedin
Welsh willbe answered in Welsh and corresponding In
‘Waith will nat lead to 0 delay in responding.
CadwDeCymruYnDdiogel
F [reroresoanaa
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Jeremy Vaughan.
‘to provide a forum to promote effective multi-agency working for people with mental
ill-health, crisis, distress and/or a learning disability coming into contact with Criminal
Justice agencies’,
South Wales Police and Health have an interest in the availability of advice for decision
making on the use of s136 (MHA 1983}, to ensure its use is necessary and proportionate to
the circumstances and a Mental Health Act Assessment ((MHAA), an obligation of the crisis
teams to conduct, is necessary.
Officers should consult with Health Care Practitioners, prior to detaining someone,
however, there remains the contingency if this is not practical, and the information and
intelligence, risk and threat assessment known indicate it is necessary, to detain, and
remove to a place of safety as defined by Section 135 (6) of the MHA 1983.
(3) The alternative support available from a mental health tactical adviser, is not provided
by a clinically qualified member of staff and does not have access to the PARIS mental
health records system.
Mental Health Tactical advisers are not currently deployed within South Wales Police, and it
is fully accepted that Mental Health Tactical Advisers will not be clinically qualified members
of staff with access to PARIS. The implementation of the provision would not replace the
need to consult with a suitably qualified professional which can include, a Doctor, Nurse, or
Approved Mental Health Professional (AMHP), who would have access to PARIS.
It remains the intention in the second quarter of 2024 to introduce this scheme which will
be based on similar arrangements in other police forces. The notion of the scheme is to
offer additional training to officers and staff in key roles, such as our Public Service Centre,
on relevant mental health legislation and associated force policy. The tactical advisor’s remit
is to offer advice to colleagues on the direction provided by force policy.
These will not serve as substitutes for our dedicated Mental Health Liaison Officers as
mentioned earlier.
Mae Heddu De Cymru yn croesawu derbyn gohebiaeth
yn Gymraeg a Saesneg, Byddwn ym ateb gnhetnseth
ddertynnis yx Gymraeg yn Gynvaeg ac ni fydd gohebu yn
yn arwain at Coch,
| POLICE
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Any
‘Welth willbe enryered in Welsh end corresponding In
‘Welsh wil not lead to e delay in responding.
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(4) The intended replacement of the mental health triage support was to have been by
the “111 press 2” service. This has not been put in to place and there is no current
timescale for it to be put into place.
The ‘NHS 111 Press 2’ service is now operating across Wales. It is available 24 hours a day, 7
days a week for all ages. (t is a means for individuals, who have an urgent mental health
concern about themselves or about someone else, to seek help and advice.
Since the concerns raised in this inquest, we have worked with NHS Wales to develop an
‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of
professionals, including the police can access advice relating to urgent mental health
concerns.
This protocol outlines that where a police officer is seeking advice in relation to the use of
section 136 (MHA, 1983) they should continue to obtain this advice from the established
crisis contact points and not NHS 111 Press 2. However, it has been agreed within the
protocol that should an officer come through to NHS 111 Press 2 and it is established that
they are seeking section 136 advice that they will be signposted to the appropriate crisis line
by the call taker.
The Implementation of ‘111 Press 2’ has resulted in a more consistent approach for advice,
which is available 24 / 7, with the ability to escalate concerns directly with local Crisis
Teams.
(5) This leaves officers with limited sources of qualified mental health advice, with access
to relevant clinical records, when responding to the risks posed by those suffering from
mental health crisis within the community.
When the Mental Health Triage was withdrawn from the South Wales Police force control
room this was widely communicated throughout the organisation for the awareness of
operational officers.
As a police force we want to be confident that procedures are known to officers, and that
they have had sufficient training. The following is a summary of the mental health training
Mae Heddtu De Gymru yn ctossawu desyn gohebiaeth
yn Gyrveeg 8 Soesneg, Byddwn yn aleb gohebiagth a
ddarloynra yn Gymvaag yn Gymrang ac ni fydd gohebu yn
Gymraeg yn orwain at onck
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‘Welsh will not leed to a delay in responding.
provision for officers which exists to prepare them to respond to mental health incidents in
the community.
New Recruits jointly trained with Gwent Police are provided with initial vulnerability
training, with all recruits receiving a 180-minute input dedicated to mental health with
defined learning outcomes.
South Wales Police officers also receive an additional 60-minute input from the Force
Mental Health Advisor around jointly agreed mental health procedures. These include the
considerations to be made in responding to vulnerable people and guidance on the use of
legislation. This input is also provided to Special Constables, Police Community Support
Officers, and newly promoted Sergeants.
In 2024 all police officers attend a newly developed public protection training day which will
reinforce key learning points to consider when responding to vulnerable people in the
community.
Our Mental Health Liaison Officers, who work daytime hours to facilitate communications
with partners, remain based within Operational Police Stations, and are a visible and
accessible source of advice.
Training for an effective mental health response is vital to ensure that our officers
understand the use of 5136 (Mental Health Act), and that they are aware of the need to
consult with a healthcare professional prior to detaining a person (if practical). The decision
to detain remains that of the police officer and not the healthcare professional providing
advice.
Medically qualified advice for officers can be invaluable to a police officer when faced with a
person in crisis and the sharing of information and opinion can be relevant to the formation
of the officer’s final judgement on the need for detention for a person’s own protection. As
such the force will continue to ensure that we work in partnership with NHS Wales and each
of the health boards to ensure that processes are effective for officers to obtain advice at
any time.
Mae Heddlu De Cymru yn croesawy derbyn gohebiseth
yn Gynwaeg a Saeineg, Byddumn yn ateb goheinseth &
ddiertngreke yn Gysmeneg yn Gymeaeg ac nifydd gohebu yn
CadwDeCymruYnDdiogel
= Gyrereng yn arwan at osc.
| ‘South Wales Police welcomes receiving
KeepingSouthw. In Welsh and Engiish. Any receivedin
falesSafe Welsh wilbe easwered in Welsh end corresponding in
‘Welsh will not fend to # delay in responding.
south-wales.police.uk €9()Q swpolice HeddluDeCymru
Whilst progress has been made on several matters discussed above, | appreciate that the
response to vulnerable people in our community can always be improved. On behalf of
South Wales Police, | provide reassurance that the improvement work continues as a
priority to ensure the organisation continues to keep people safe, and they receive the right
response from the right agency.
| hope that this response addresses the concerns that you set out in your report, and | am
grateful for you bringing them to my attention.
Yours Sincerely
Assistant Chief Constable
Specialist Crime, Criminal Justice, and Safeguarding Command
Mee Heddiu De Gymru yn crossawu derbyn gohebiseth
yn Gymraeg a Saesneg, Byddwmn yn ateb gohebett a
dderbyrne yn Gymraag yn Gymraeg ac rv fydd gohebu yn
yr arwain at oock
South Wales Pole welcomes racelving correspondence
tn Welsh and English. Any comespondence received in
CadwDeCymruYnDdiogel
‘Welsh wil not leed to 0 delay in responding.
south-wales.police.uk €}(6)@ swpolice HeddluDeCymru
POLICE
| HEDDLU
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