Michael Crane

Prevention of Future Deaths Report 
Michael James Crane (date of death: 18 January 2024) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

Metropolitan Police Commissioner 
New Scotland Yard 
London 
SW1A 2JL 

1 

CORONER 

I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 

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 

On 2 February 2024, an investigation was commenced into the death of 
Michael James Crane, then aged 54 years. The investigation concluded at 
the end of an inquest heard by me on 26 September 2024. 

The inquest concluded with a short narrative conclusion in the following 
terms: “Drowning in the river Thames, contributed to by the fact that no 
missing person report had been made to the police.” The medical cause of 
death was: 

1a drowning  
II idiopathic left ventricular hypertrophy related cardiomyopathy 

4 

CIRCUMSTANCES OF DEATH 

Michael Crane lived in supported accommodation for those living with mental 
health diagnoses, at Island Place Residential Home (the Home) in Leicester. 
His past medical history included schizophrenia, complicated by substance 
misuse, and he was under the care of mental health services in 
Leicestershire, by virtue of a Community Treatment Order. His schizophrenia 
was treated with monthly depot injections, the next of which was due on 16 
January 2024. 

Sometime during the afternoon of 15 January 2024, Mr Crane was noted to 
be ‘off Unit’ by staff at the Home. He had still not returned home by 23:00 that 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 evening. Further checks at 03:00 and 07:00 on 16 January 2024, still noted 
Mr Crane’s absence from the Home. While he was noted to be absent, no 
action was taken because he was deemed to be ‘low risk’ and had the 
freedom to come and go from the Home as he wished. The standard policy at 
the Home was that they only reported residents missing once they had been 
unexpectedly absent from the premises for 24-hours. 

At about 05:54 on 16 January 2024, Mr Crane had self-presented to the 
Emergency Department at St Thomas’ hospital (the Hospital), London, having 
previously spoken to Metropolitan Police Service (MPS) officers. He was 
assessed by the Mental Health Liaison Team at the Hospital and there was 
no indication that he needed to be admitted under the Mental Health Act at 
that time; the plan was to assist Mr Crane to get back to Leicester so that he 
could have his depot injection that day, as planned. 

At about 08:30 on 16 January 2024, the Home received a telephone call from 
the MPS to advise that Mr Crane had gone to the Hospital. The Mental 
Health Liaison Team at the Hospital also telephoned the Mental Health 
services in Leicestershire that were caring for Mr Crane’s mental health 
routinely.  

Shortly after 11:55 on 16 January 2024, Mr Crane was escorted off-site at the 
Hospital by a member of staff for the purposes of having a cigarette. 
However, he left and was seen to board a bus bound for Victoria station. 

No service had reported Mr Crane missing at this stage. 

At approximately 16:40 on 16 January 2024, Mr Crane approached two MPS 
officers on The Strand and asked them if he was a missing person. The 
officers undertook some checks and advised Mr Crane that he was not a 
missing person. Mr Crane went with the officers to Charing Cross police 
station. 

The officers were aware that Mr Crane had been at the Hospital that morning. 
They also considered that he was dressed inappropriately for the weather 
conditions and noted that he was referring to ‘hearing voices’. However, they 
formed the view that he was generally coherent and there were no grounds to 
detain him under section 136 of the Mental Health Act. One of the officers 
telephoned the Home, who advised that they had not reported Mr Crane 
missing but that they intended to do so in about 30 minutes’ time. 

At about 17:30, the officers noted that Mr Crane was becoming more and 
more anxious to leave the police station and they allowed him to do so. 

CCTV footage showed that having left Charing Cross police station at about 
17:30, Mr Crane spent about 35 minutes in the general vicinity. His 
whereabouts thereafter are not known. 

At approximately midday on 18 January 2024, officers from MPS Marine 
Policing Unit retrieved a body from the river Thames, near Free Trade Wharf. 

 
 
 
 
 
 
 
 
 
 The body was identified as being that of Michael Crane, who was still wearing 
the wristband from his brief admission to the Hospital. 

At the time of retrieving Mr Crane’s body, the Home had not reported him 
missing. 

It is not possible to say how, where or when, Mr Crane entered the water. 

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 could occur unless 
action is taken. In the circumstances, it is my statutory duty to report to you. 

The MATTER OF CONCERN is as follows: 

• 

• 

1)  The MPS constable who gave evidence at the inquest, told me that: 
if Mr Crane had been reported missing at the time he was in 
Charing Cross police station then there would have been more 
that officers could have done to keep him safe; 
the fact that officers had heard (directly from staff) that the 
Home intended to report Mr Crane missing within the next 30 
minutes, did not mean that there was more that the officers 
could have done at the time; and 
there was not, either at that time or to date, any MPS guidance 
to frontline officers in relation to how to approach their powers 
under section 136 of the Mental Health Act or in relation to 
people who are likely to be missing but have not yet been 
reported as such. 

• 

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 
the report, namely 6 December 2024. 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 Chief Coroner and the following: 

• 

(

 – brother of the deceased 

)  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Prime Life Limited 
Caernarvon House 
121 Knighton Church Road 
Leicester 
Leicestershire 
LE2 3JN 
(

)   

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. She may send a copy of this report to any person who she 
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 

Ian Potter 
HM Assistant Coroner, Inner North London 
25 October 2024

Our Ref: 

HM Assistant Coroner Ian Potter 
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London 
N1C 4PP 

Dear Mr Potter,  

Deputy Assistant Commissioner 
Metropolitan Police Service 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email: 

20 December 2024 

I would like to start by expressing my sincere condolences to the family and friends of Mr Michael Crane. 

On behalf of the Commissioner of Police of the Metropolis, I write to provide our response to the matters of concern 
addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths, dated 25th October 
2024, following the inquest into the death of Mr Michael Crane.   

The Coroner’s “Matter of Concern”  

“The MPS constable who gave evidence at the inquest, told me that:  

• 

• 

• 

if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have 
been more that officers could have done to keep him safe;  
the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within 
the next 30 minutes, did not mean that there was more that the officers could have done at the time; and  
there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to 
approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be 
missing but have not yet been reported as such.” 

MPS Response:  

Training and Guidance in Mental Health 

The MPS recognises that staff will come into contact with people in crisis for a variety of reasons, including mental 
health. The MPS runs a scenario based approach to Public and Personal Safety Training (PPST), focusing on different 
interactions an officer is likely to face in the course of their day to day duties. It includes steps that can be taken to 
manage interactions as effectively as possible. This training is mandatory for all operational police officers. All new 
recruits receive eight days of training and all police officers receive two days refresher training each year.  

Officers are directed to attend training centrally. Compliance is monitored, and attendance recorded through the 
corporate Learning Management System (LMS). This is an industry recognised computer-based system which holds 
individual training records for each officer in the MPS. In the event of an officer not attending training, this will be 
flagged to a supervisor and they will be directed to attend training. Prior to the LMS system going live in 2022, 
officers were directed by e-mail and when they completed their training, an alert was sent to HR for records to be 
updated on the central HR system known as the Police Standard Operating Platform (PSOP).  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 The MPS provides all police constables with a mental health input during their foundation training, albeit the content 
varies depending on the date of joining, and will reflect the current policies and legislation at the time the training 
was designed.  

The following principles are woven into lessons and scenarios, and this training is delivered to all new recruits 
irrespective of which pathway they enter the MPS:   

Tactical communication 

This lesson is part of the recruit syllabus.  Potential barriers to communication, including mental ill health, are 
contained within it.  The Trainer Resource Pack comprises the following text:  

“Mental Ill Health: Officers are not expected to diagnose mental ill health in individuals that they come into contact 
with. Officers may however become aware, by a variety of means, that the person they are dealing with is believed to 
be experiencing mental distress or ill health.”  

Safety in mind 

•  A video is presented which has been created in conjunction with the London Ambulance Service and South 
London and Maudsley Hospital. It is aimed at, not only police officers, but others who may find themselves 
dealing with people in a mental health crisis. A discussion takes place regarding this input. It was created to 
coincide with the introduction of the Vulnerability Assessment Framework (VAF) following a report by Lord 
Adebowale.   

•  The VAF highlights how people may be vulnerable, for various reasons (not limited to mental health), and 

provides a list of indicators for officers to look out for when assessing vulnerability. This includes: Appearance, 
Behaviour, Communication (how are they communicating), Danger (to self or others), Environment (ABCDE 
assessment).  
It also includes the CARES mnemonic, which is how officers should approach vulnerable people (“Contain rather 
than restrain, Approach within view of the person, Reduce distractions, Explain what you are doing, Slow down 
your actions), and the role of the safety officer.  

• 

•  The focus of the lesson is in dealing safely with people who appear to be experiencing a mental ill-health crisis 

and the subsequent handover to medical professionals.  

Vulnerable person scenario 

•  The Scenario Based Training (SBT) annual PPST refresher training introduced in April 2024 includes a “vulnerable 

person” scenario. This focusses on dealing appropriately with a person in crisis (whatever the cause) and 
specifically includes CAMERAS (C: Contain the person, and avoid or restraint if possible, A: Continuously update 
the ambulance, M: Monitor the person's vital signs, E: Explain what you are doing to the person and their family, 
and use friends and family to help reassure them), CARES and the VAF in the associated “time on task” activities.  

•  The SBT approach, including the vulnerable person scenario, are due to be introduced to recruit PPST in 2025.  

In early 2019, the MPS reviewed the mental health training that was delivered to officers and developed a bespoke 
one-day training package. The content was based on the College of Policing Authorised Professional Practice (APP), 
the London Crisis Care Pathway and the MPS Mental Health Toolkit. It incorporated relevant legislation (including 
the Mental Health Act 1983) and the voice of the service user, lessons learnt; and tested learning through a series of 
animated scenarios. It encouraged officers to implement their learning as well as seeking to highlight the 
perspectives of service users and mental health professionals. This training was concluded in April 2020 and has 
been delivered to 10,300 officers.   

The College of Policing have developed APP which can be accessed online by all police officers. It is the official and 
most up to date source of policing practice. It covers a range of policing activities including an APP for mental health.  
It covers: strategic considerations; mental vulnerability and illnesses; mental health and detention (including Police 
Powers under Section 136 of the Mental Health Act 1983); mental capacity; mentally ill patients who are absent 
without leave from recognised care; safe and welfare checks and crime and criminal justice. 

2 

 
 
 
 
 
 
 
 The MPS had a Mental Health Toolkit up to July 2024. This was a living document containing guidance for officers on 
how to deal with all aspects of people who are mentally unwell or have mental illness. This has now been 
superseded by the Mental Health Share Point page which provides guidance and is also interactive. It contains 
sections on all topics of policing and mental health and has links to the associated legislation. 

Use of Powers under section 136 of the Mental Health Act 1983 

Section 136 of the Mental Health Act 1983 (s136 MHA) is the most commonly used piece of legislation by officers at 
mental health incidents. 

It is a preserved power of arrest that allows for an officer to detain someone that they believe to have a mental 
disorder and to be in immediate need of care or control and to remove them to a place of safety.  

The power to remove a person requires three conditions to be fulfilled before police act: 

1.  The person must appear to the officer to be suffering from mental disorder. 
2.  They must appear to the officer to be in immediate need of care and control. 
3.  The officer must think that it is necessary to remove the person in their own interests or for the protection of 

others. 

The police officer is not expected to make a diagnosis of someone’s mental state 

As previously mentioned, the training is very clear on what the expectations are of police officers when dealing with 
an individual suffering mental ill health. The s136 MHA power provides officers, who believe in good faith that 
someone is mentally ill and requires immediate care or control - to remove them to a place of safety where they can 
be examined by a registered medical practitioners and be interviewed by an Approved Mental Health Professional 
(AMHP), who can make any necessary arrangements for the individual’s treatment/care. 

The officers dealing with Mr Crane acknowledged that Mr Crane had been at hospital for his mental health earlier 
that day, that he was inappropriately dressed for the weather conditions and that he was ‘hearing voices’. However, 
they formed the view that whilst Mr Crane did appear to be suffering from some kind of mental disorder (hearing 
voices), he was not in immediate need of care and control, and they did not deem it necessary to remove him to a 
place a safety. The conditions of use for s136 MHA therefore were not made out. The fact that officers did not 
invoke their powers under s136 MHA does not mean there was inaction on their part.  

The officer that provided evidence at the inquest indicated that he understood his powers very well in accordance 
with the law and treated Mr Crane with empathy and care.   

Missing Persons Guidance 

The College of Policing/APP 2017 definition of a missing person is: 

“Anyone whose whereabouts cannot be established will be considered as missing until located and their wellbeing or 
otherwise confirmed.” 

Under this definition, the circumstances of an individual’s whereabouts simply being ‘unknown’ could result in the 
expectation that police are responsible for locating them, regardless of the circumstances. This is impractical, with 
unnecessary deployment being potentially damaging to the individual (e.g. breach of privacy), or by limiting the 
overall capability of police to respond effectively to missing persons (e.g. due to high levels of unnecessary and 
preventable demand).  

To manage this, when an individual is reported missing, we must first consider whether there was any reasonable 
expectation or necessity for police to be informed at all. Mr Crane was not reported missing to Police and his 
whereabouts were largely known during his time away from the care home.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The officers were aware that Mr Crane had been at the hospital that morning. They also considered that he was 
dressed inappropriately for the weather conditions and noted that he was referring to ‘hearing voices’. However, 
they formed the view that he was generally coherent and there were no grounds to detain him under s136 MHA.  
One of the officers telephoned the care home, who advised that they had not reported Mr Crane missing but that 
they intended to do so in about 30 minutes’ time.  The officers noted that Mr Crane was becoming more and more 
anxious to leave the police station and they allowed him to do so, as they had no policing powers to detain him. 

Even in the event that Mr Crane had been reported missing, the officers options were extremely limited. They had 
already formed the view that he did not meet the criteria for s136 MHA to be used and as Mr Crane was an adult, 
there were no other policing powers available to them. The care home were informed where Mr Crane was and 
provided no further details to the officers as to any risk Mr Crane may have posed to himself/others or any further 
details about his mental health that could have raised the risk to him.  

If there was heightened risk to Mr Crane, it was for the mental health professionals or care home to make this clear 
throughout the multiple touch-points across the agencies on 15th or 16th January and this includes the best 
opportunity of all when the officer called to inform the care home they were with Mr Crane at the Police Station.   

Please do not hesitate to contact me should you require any additional information or clarification regarding the 
contents of this response. 

Yours sincerely, 

Deputy Assistant Commissioner 

4

Connor Greaves 
121 Knighton Church Rd, 
 Leicester, 
 LE2 3JN. 
18.11.24 

Dear Mr. Potter,  

I refer to the prevention of future deaths report you issued following the conclusion of the  
inquest touching upon the death of Michael James Crane.  

For ease of reference and clarity, we have used the topic headings provided in your report and 
responded accordingly: 

• 

staff at the Home did not follow the Home’s own policy to report a resident missing once 
they have been unexpectedly absent for 24 hours.  

I have gathered the below chronology-  
15th January- MC had spent the day in and out of island place, had taken his meds and appeared 
settled, he had made a request to the senior for her to contact his social worker as he had been 
without money for weeks. 
15th January 19:00- MC was noted to be off unit at 19:00 by staff.  
16th January – 05:54- MC presented himself at a police station who taken him to St Thomas Hospital 
after attending a police station in London claiming to be unwell. 
16th January 08:30- the police in London called Island Place to advise that MC had gone to hospital 
and that the mental health team had been in touch with MC’s Leicester mental health team and 
were caring for his mental health routinely.  
At this point MC had been off unit 13.5 hours and was not reported missing because he was not 
missing, we knew he was at St Thomas’s hospital in London and therefore did not need to report him 
as a missing person.  
16th January 11:55- MC was escorted by a member of the hospital staff for a cigarette however he 
left the hospital and was seen boarding a bus bound for Victoria station.  
16th January 12:00- St Thomas hospital called Island Place and said MC had absconded from the 
hospital.  
16th January 16:00- Senior at Island Place called St Thomas hospital to see if he had returned and he 
had not. 
16th January 17:30- PC Cante from town croft police called to say they had approached MC in the 
street to do a welfare check on him and they asked if he was under any section, police said MC 
expressed he wasn’t ready to return to Island Place and they didn’t have any hold over him. Police 
gave Mc the homes number and said to present himself to the police station or the hospital when he 
is ready to go back to Island Place, police said he did not seem like a threat or a concern. 
 The home had not reported him missing yet due to him only leaving hospital at 11:55, however they 
were going to report him missing shortly before this call due to him absconding from the hospital, 
they then made the decision not to as they had spoken to the police at 17:30 and again, he 
technically wasn’t a missing person.  
16th January 18:00- after spending 30 minutes in the general vicinity of charing cross police station 
MC leaves the area and his whereabout are then unknown.  

 
 
 
 
 
 
 
 
 
  
 
 16th January 23:00- police from Charing cross call Island Place to see if MC had returned to Island 
Place  
17th January- throughout the day- Island Place had been in touch with MC mental health team as 
MC was under a community treatment order and could be recalled back to hospital, MC responsible 
clinician agrees to recall MC back to hospital for treatment and issues the recall paperwork. The 
paperwork is received at Island Place at 17:00  
17th January- 17:00- Island Place report MC missing to the police as it had been 23.5 hours since last 
hearing of his whereabouts and he had been recalled to hospital by his responsible clinician- incident 
number 465/17.01.24- reported to 
18th January 12:00- MPS marine police unit recover a dead body from the Thames which is 
identified as MC.  
18th January 19:00- MPS called Island Place to inform they had found him deceased in the river 
Thames- reference number 

- collar number 7903. 

.  

This suggests that Michael was reported as a missing person on the 17th January, after he had been 
missing for 23.5 hours, the rational around not reporting him missing prior to this time is that he 
wasn’t actually missing, we had been informed of his whereabouts and had been kept up to date on 
his location, there was no suggestion that Michael lacked capacity and therefore it was his right to 
come and go from our premises as he wished.  

• 

staff seemed vague and confused about what, if anything, they should do once they became 
aware that the resident had been found by the police in London.  

There is a clear policy regarding what to do once they become aware of a missing resident, Michael 
had full capacity to travel wherever he wanted and therefore there was no action for the staff to 
take when they had contact from the police in London.  

• 

staff advised the police in London that they intended to report the resident missing but then 
did not proceed to do so.  

On the 17th January, after Michael had been missing for 23.5 hours and the staff had not had contact 
from either home or any relevant professionals, Michael was reported as a missing person to 
Leicestershire police and there was the relevant paperwork completed by his responsible clinician in 
order to recall him to hospital for an inpatient stay, as part of his community treatment order 
conditions.  

•  details about any additional training or steps taken to reduce the risks were very vague.  

Prime Life offer a comprehensive induction and training schedule which allow ongoing education 
and professional development, the training data at the time of the tragic incident were well within 
our internal KPI, additional steps to reduce risk were limited due to Michael having full capacity 
around his day to day living, it was his right to go to London and was his right not to stay at the 
service if he didn’t wish to, the staff supporting Michael at the time were not duty bound to extend 
this support into the community when Michael decided to leave Island place and head towards 
London.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  details of specific policies and procedures in place at the time were vague. 

There are a full set of policies and procedures available to all staff, which have since undergone a full 
review.  

•  There was clear evidence from MPS officers that had the resident been reported missing, 

they could have done more to protect and safeguard the resident. 

At the time of their contact with Michael, he was not a missing person, the home had not reported 
Michael missing as they had contact with the hospital and the police regarding Michaels 
whereabouts and therefore didn’t see it necessary to report him as a missing person, it was only 
after a longer period of no contact that the home reported him missing, as it had been 23.5 hours 
and his responsible clinician had issued the relevant paperwork in order for Michael to be recalled to 
hospital under his community treatment order terms.  

Conclusion-  

As a provider we are committed to learning lessons from incidents such as the tragic one with 
Michael, since this incident we have reviewed our missing person policy and have provided 
additional training to the staff and management at Island Place in order to ensure that they have 
clear guidance on when and understanding in how quickly a person should be reported missing.   

I would like to end this report, by sending my condolences to Michaels family and friends.  

Yours sincerely,  

Connor Greaves  
Associate Director  
On behalf of Prime Life Ltd.