I continue to read the website of the Chief Coroner, where Preventing Future Death (PFD) reports are published and came across the recent notice after the inquest for Mr Anthony Preston, in Essex.  Many PFDs raise similar issues and I’ve written before about what PFDs are and collated many of those which I think are relevant to claims of lessons learned.  I’ve now added the notice for Mr Preston because I think it shows in PFD form issues which haven’t been raised in such notices previously.  My point here is, that they are common dilemmas which are all-too-thankfully not related to deaths.  I’m keen to emphasise this PFD notice precisely because it’s always been obvious they could be and if ’lessons learned claims’ are to be taken seriously, then this report needs notice, in my view.

I encourage you to read the entire notice, not least to see evidence from the Coroner of things I will mention which will surprise you and which you’d be entitled to question if I weren’t showing the source of the claim.  That said, a summary of the...

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Worth reflecting on a few issues to do with the return, recall or revocation for those patients who are absent without leave (AWOL) or liable to be detained, under the Mental Health Act 1983.  I’ve had a number of queries, questions and quandaries in that last few weeks so I thought a post on it may help.  This post relates, therefore, to patients who either are or at some point were sectioned in hospital under the MHA and are now outside the hospital in one of several circumstances —

• Some patients may have left the hopsital without authorisation and are AWOL.
• Some may have had such authorisation but have failed to return to hospital on time – and are now also AWOL.
• Some patients may have had such authorisation cut short by service of a notice revoking their s17 leave – and are now AWOL.
• Some patients may have been previously discharged from hospital on a Community Treatment Order and then been recalled from that – and are now AWOL.
• This list is not exhaustive – could do on to add s42 warrants or recall and so on so consider wider...
  
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One year ago, Victor Osei killed his neighbour Anthony Higgins in a brutal attack.  Having pleaded guilty to manslaughter on the grounds of diminished responsibility, Mr Osei has been given a hospital order “without limit of time”, (presumably, a s37/41 restricted hospital order) and will be detained until such time as his psychiatrist and the Ministry of Justice are satisfied it is appropriate for him to be discharged.  The psychiatrist who gave evidence in the criminal proceedings, Dr Nigel Blackwood, seems to have been keen to stress the supervision which follows discharge after a homicide, noting that it is different to community care which is provided before a patient has seriously offended.  Conditional discharge, as it is known, allows the hospital or MoJ to recall any patient to hospital if there were to be a repeat of non-compliance with medication, for example.

I’m obviously now blogging a lot less frequently than before and trying to avoid individual commentaries on cases where all I have is the same news article as...

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I’m all too wary of newspaper coverage of cases which have appeared in courtrooms.  Having been directly involved in enough cases to know that coverage is necessarily partial, it often misses things which can be important to understanding what has occurred.  In fairness to newspapers, they have a few hundred words to summarise hearings whose case papers can sometimes require a porter’s trolley to wheel in a number of packing cases, so things will be left out!  It often means I read coverage and then say to others that I “have one or two hundred questions about all this.”

The Manchester Evening News’s recent coverage of the inquest after the death of Mr Martin Gibbons was especially interesting for a specific reason.  In just two short sentences, the coverage made a claim about the assessment and response to Mr Gibbons when he was in an Emergency Department (ED) which just made me wonder about things more generally.  Events leading to Mr Gibbons tragic death included his deteriorating mental health, discussion of difficulties with his...

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A month or so back, on Sunday nights, the BBC aired episodes of Jimmy McGovern’s “Time“, a drama about the prison system.  It was the best television I’ve seen in years and I ended up watching all three episodes, as if it were a film.  I’ve since re-watched it all and I hope it goes on to win recognition for its writing, acting and representation of the prison system.  Former prisoners and prison officers alike have commented that it’s the best representation of the reality of prison they’ve ever known.

Seen from mostly from the dual perspective of an English teacher (Mark, played by Sean Bean) convicted of causing death by dangerous driving whilst drunk and a senior prison officer, it took only a matter of minutes for the issue of mental health to be front and centre.  It was impactive and graphic, almost distressing.  Actor Stephen Graham (who plays prison officer Mr McNally) said in publicity ahead of the broadcast that he wanted his work to be uncomfortable to watch and it certainly was.

Spoiler alert! – please don’t read on if you’ve...

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In 2018, Professor Sir Simon Wessely concluded his review of the Mental Health Act 1983 and recommended certain actions.  In early 2021, the Government announced a consultation about the White Paper and today, they have published their response. To their consultation

This is an early post after a relatively light read.  It highlights the main points of the review as they affect the police service.

POLICE IMPLICATIONS

There are only two main issues emphasised, in addition to the general need for ‘awareness’ and improved focus in policing and the broader criminal justice system (for example around neuro-diversity).

But the two particular points are —

• Mental health holding powers for Emergency Departments —
• Currently, no-one in EDs perceived to be at risk can be subject to a ‘holding power’ under the MHA.
• There is endless, unresolved debate about the extent and applicability of the Mental Capacity Act in those circumstances.
• The Government White Paper therefore proposed ensuring clarification that ED staff could detain people they...
  
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Recent news coverage touched on the fact a family were not told that the man sentencing to life for killing their son had been transferred almost immediately to a hospital.  In 2019, Brian Heelless killed Alex Davies in a brutal attack with a knife.  After being sentenced to life in prison, Mr Healless was moved almost immediately to a medium secure hospital and  this has caused understandable consternation which I thought may be worth explaining, not least because I can see why it raises immediate and obvious questions about the will of the Crown Court and the consternation appears to have been made worse by Mr Davies’s family not learning what had happened until many weeks later.

Let me explain the background –

Brian Healless denied murdering Mr Davies during his trial but admitting killing him and he argued the ‘diminished responsibility‘ partial-defence.  This would mean, in short, that he accepted a level of culpability for the killing, amounting to manslaughter, but amidst a context where his reasoning and functioning were affected...

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For a couple of years, I’ve been regularly reading the website of the Chief Coroner, in particular the section on Preventing Future Deaths and I’ve blogged about this before.  I had a discussion with an academic last year about the potential of me undertaking PhD research on PFD issues affecting policing and mental health, not least because of the obvious potential to argue that lessons from these notices are not always fully learned.  To the extent that they are, usually by the organisations directly affected, they are not necessarily learned more widely across agencies and across the country.  In my recent reading, I kept a list of cases with at least some bearing on policing and mental health issues and thought it may be useful to provide links and summary comments about those which stick out, at least for me.

GREATER DISSEMINATION

Where a death occurs and a PFD notice is issued to police force X, will police force Y know about this and learn from it?  Will Ambulance Trust Y and Mental Health Trust Y know about this and learn from it...

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I’ve recently being doing some research on Preventing Future Death notices and putting together a list of notable examples around a few different themes.  The notice from January 2020 after the death of Mr Thiago Araujo is especially interesting around the topic of s135 MHA assessments and it’s not the first notice in recent years to touch upon this.  The Coroner lists a number of areas of concern but it’s numbers 4 and 5 which caught my attention – the acknowledgement that re-admission to hospital may be required and the process and requirements for an assessment under s135(1) Mental Health Act 1983.

Where someone is believed to be in a private premises is thought to need assessment for consideration of their admission to hospital, an Approved Mental Health Professional (AMHP) can make an application to a Magistrate for a warrant under s135(1) which then allows the police to force entry to the premises, if necessary, to allow for assessment.  That assessment can either occur in the premises itself, if the person consents, or the police may...

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In December of 2015, NHS England published a Patient Safety Alert (PSA) on the topic of medical ‘observations’ following restraint.  A PSA is notification to NHS Trusts across the country of an emerging topic that requires urgent attention by healthcare providers to check that their own procedures are consistent with the latest guidance in the alert.  This document reminds us that risks during restraint are quite well known before adding, “harm can also occur in the period following restraint from the effect of illicit substances, alcohol, prescribed medications (including any rapid tranquilisation) and co-existing medical conditions. People with diagnoses of severe and enduring mental illnesses are at increased risk of coronary heart disease, cerebrovascular disease, diabetes, infections, epilepsy and respiratory disease, all of which can potentially be exacerbated by the psychological and physical effects of restrictive intervention; between 2008-2012 there were 11 deaths within 24 hours of restraint in mental health settings in...

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