A new Preventing Future Deaths report will be of relevance and interest to those involved in knowing more about this topic area.
A side-note to begin with: I regularly read the website of the Chief Coroner, where PFD notices are regularly uploaded (and often the responses of organisations) – it always feels inappropriate, as if being nosey about the darkest tragedy of a family I’ve never met, pouring over the details of their loved one. It’s important to do, however. I remain convinced that PFD notices are a treasure trove of learning and because I agree with Deborah Coles (the Director of Inquest) about a “repeated failure to learn repeated lessons”, I feel it’s important to highlight the learning, even at the risk of feeling invasive. I hope it’s seen as the attempt it is, to capture the lessons and the learning for those who read this blog.
Rebecca Fisher was found deceased by her own family – a horror situation I can only begin to contemplate. The search for her followed her failure to return from 30-minutes of authorised leave from a mental health unit in Greater Manchester and a failure of the police service to which she was reported missing to treat her as high risk. Rebecca had been admitted to the ward on a voluntary basis with complex mental health problems after a crisis incident and the coroner wrote in the PFD notice that it was recognised as a risk that she was granted leave. She took the view the ward were correct to consider Rebecca at high risk after the failure to return and NHS staff reported her missing to Greater Manchester Police (GMP). The PFD notice was sent only to the Chief Constable of GMP, not the trust and that tells us where the Coroners concerns lie.
MATTERS OF CONCERN
Four areas —
- Poor understanding that voluntary patients can still be high risk if they failed to return from leave;
- Lack of understanding use of short periods away from the unit to support a patient’s recovery did not mean they could not be high risk if they failed to return;
- Lack of understanding of how to apply the golden hour guidance and what was the expectation coupled with a lack of understanding by some officers about accessing mobile phone data such as cell site; and
- Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The last post I wrote was specifically about the legal concept of an ‘immediate risk to life’ and it’s of relevance here as well. It focussed on the legal significance of a Supreme Court case (links within the post just given) which oddly enough also followed the tragic loss of a young woman called Melanie Rabone who had been a voluntary mental health patient in a Greater Manchester mental health ward (although in that case, failings sat with the NHS, not the police).
VOLUNTARY PATIENTS
The coroner’s four points of concern, above do a pretty good job in writing this post for me, so there’s not much more to say. It’s just important to remember that the distinction between a voluntary and a formally detained mental health patient is, to quote Lord Dyson in the Rabone judgment, “one of form, not substance”. He stated the differences between a voluntary and detained patient “should not be exaggerated”. So the messages you need to take away from reading this post is we shouldn’t assume lower levels of risk just because a) the person was a voluntary, not a detained patient; and b) the hospital had allowed her to have leave.
- Neither of these facts mean that upon a failure to return from leave the risk cannot be high;
- And the final important lesson is this – GMP witnesses at the inquest continued to insist Rebecca was not high risk: despite the NHS stating she was.
- This point was reinforced by the coroner in the PFD under the four areas of concern.
I’ve heard it asked a lot (and frankly, I’ve asked myself when I knew less about it) “Why did they grant leave if failure to return would mean high risk?! – surely that’s putting the patient at risk.” To put the same concern a different way, “If the person would be high risk when out of hospital, they wouldn’t have granted leave in the first place!” Neither of these thoughts is worth having or entertaining: it’s missing the point entirely.
LEVELS OF RISK
The question is to focus on the perceived level of risk in play and we need to remember what a “real and immediate risk to life” actually is, as outlined above in the Rabone case.
- It’s simply not correct to assume that someone going missing must mean allowing leave was inappropriate;
- It’s simply not correct to argue that the grant of leave means the risk was always going to be lower than high.
Remember: the same mental health trust who were found wanting in the Rabone case were the trust reporting Rebecca missing to GMP – they were attempting to ensure they had discharged their responsibilities by engaging an organisation who then had an operational article 2 duty to consider: does Rebecca’s failure to return amount to an ‘immediate risk to life’; and if so, have appropriate steps been taken to reflect the obligation to what is reasonable to mitigate that risk? This would include good risk assessment and proper process around a high risk missing person, including urgent work on her mobile phone to narrow down search parameters and find her.
And these are lessons to be learned to prevent a repeated failure to learn repeated lessons.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 