Very sad to read a new Preventing Future Death report from Durham, after the death of Mr Kenneth Rippon. He died after jumping or falling from the railway viaduct in Durham whilst seriously unwell. The PFD makes it known he died despite the best efforts of police officers to negotiate with him and ensure a safe outcome. Of course, after Mr Rippon fell, paramedics and police officers would have needed to establish if he could be saved, albeit that seems unlikely – I know the viaduct and its height must surely render survival very unlikely. Fast forward to the inquest and if the officers or paramedics involved had seen the background to Mr Rippon’s presence on the viaduct, they must have wondered how they ended up having to negotiate at all.
The Coroner raises a number of matters of concern but they all revolve around the failure of relevant agencies to conduct a serious incident review in a timely way after the fatal outcome, to ensure lessons are learned. The narrative section of the PFD outlining circumstances shows there was a lot of potential to highlight. Mr Rippon died on 5th May having presented three times to A&E on the 2nd, 3rd and 4th of May. On the first two occasions, he presented via the ambulance service after consuming materials which would cause him harm and making it clear he did not feel safe at home because of command hallucinations telling him to ingest those substances. On each occasion, there was no comprehensive mental state examination and the staff involved did not have access to relevant, background risk information.
On the 4th May the situation was similar, except that he made it clear he would attempt to take his own life if he was not admitted to hospital because he didn’t feel safe at home. Having been discharged despite his stated intention, he was waiting for transport and then left before it arrived. Reported missing to the police, he was graded as “medium risk” based on the incomplete information provided to the police by mental health services. Worth noting it was stated mental health services reported him missing, not the Emergency Department – I’m not sure the significance of that, except to note if mental health services were involved, as opposed to ED staff only, then it renders more relevant the incomplete mental health assessments.
MATTERS OF CONCERN
Various thoughts occurred –
- Following presentations to Emergency Departments of this kind, there is meant to be comprehensive assessment of people and their mental health. We know this occurs only some of the time and nothing in this PFD reassures us that it happened in Mr Rippon’s case.
- I was left wondering about communications around the ‘immediate risk to life’ and ‘immediate risk of serious injury’ criteria for Article 2 and Article 3 obligations – those obligations belong to NHS staff and organisations as much as they belong to the police and I was left wondering whether anyone was asking about the risk to life or risk of serious injury if Mr Rippon left the department on any of the three occasions before his death on 5th May.
- But mostly I was prompted to write this post by wondering what the involved police officers or paramedics would think about the who build up to an event which is quite likely to stick in their memories for life. Not just the rest of their careers – but for the rest of their lives.
I can predict now that I’ll be able to vividly recall the guy who set himself on fire in front of me about a decade ago – it’s not something I’ll ever forget, even long after I stop doing the job I do. You can unsee that stuff and I know enough about the background to that incident to know it was unpredictable and unavoidable. I’m left wondering how I would have felt if it were otherwise. We know that mental health and PTSD rates in about the blue and green emergency services are sky-high compared to the working population as a whole – is it any wonder, with incidents like this and their known backgrounds? What does it do to you, to wonder whether you should have even been in that position at all?
And as with so many inquests I was left wondering a number of questions about the PFD –
- The matters of concern all relate to the delays and problems with the serious investigation report from the mental health trust.
- None of them relate to the potential for future deaths if those of us attending an Emergency Department are not properly assessed after attempts to self-injure
- None of them relate to the potential for future deaths if those of us attending Emergency Departments are discharged away after open admissions that we will hurt or kill ourselves if not protected, especially where it is the third ED attendance in as many days.
Finally, I’m constantly finding reasons to be reminded that appetites for risk management are very different in policing and in mental health (or health) services – this is another example, because three incidents of serious self-injury or stated intentions to die by suicide did not lead to mental health assessment, never mind Mental Health Act assessment for consideration of compulsory admission to safeguard the man.
It’s just all kinds of sad, on various different levels but especially to Mr Rippon’s family and friends. My condolences to them all.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions 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
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