An inquest concluded at the beginning of the week after the tragic death of Michael Holland in Sussex at the end of 2021. There is quite a long narrative to the events which led to Mr Holland’s death and I would encourage those who want the full detail to read the press release from Inquest, potentially before continuing here. For this post, I’m interested in those significant aspects which affect the emergency services and that will involve enough detail to fill a post, hence my referring you to the inquest website if you want the broader background.
Mr Holland was detained by the police under s136 of the Mental Health Act 1983 in October ‘21 and ‘sectioned’ to a mental health unit after his mother raised concerns for his welfare. The whole tale is one of an obviously caring, devoted mother trying to do her best to keep her son safe and well, as best she can. Two months later, Michael was discharged from detention under the Act, notwithstanding representations from his mother that he was, to her, still obviously delusional and unwell. Nevertheless his discharge proceeded, as it all too often does.
Ordinarily, patients discharged from detention in hospital under the MHA are seen by their community team within 72hrs. For various reasons, this did not happen. The press release implies someone had attended Michael’s address but received no response and despite the fact Michael’s mother had made it known she had a key, this information had not been recorded so no-one contacted her to achieve access to his flat. Attempts were made to contact Michael by telephone, not withstanding his mother had explained he’s unlikely to answer. The ambulance service was asked to undertake a welfare check.
EMERGENCY SERVICES
Late on the 1st December, the ambulance service did attend and the press release states they were accompanied by the police. I’m interested in the question of this police support – was it assumed that because there had been no reply to the attendance and the phone call, that it was considered there was a risk to life and hence officers may be required to force entry to the property? That seems the most obvious reason, but the press release is non-specific about that. It certainly occurred to me the question should be considered whether this was an ‘immediate threat to life’ incident, whilst accepting that some may argue it was not.
Officers did force entry just before 11pm, I was glad to learn: the crews found Michael in a condition of injury, having cut himself with a knife and he claimed he had taken “shit loads” of morphine, several empty packets being found in a nearby bin. The ambulance crew obviously undertook an assessment and concluded it was appropriate to leave Michael at home, he had assured them sufficiently to give them confidence this was the correct approach. Nothing is noted in the press release about what feedback was given to the mental health trust who had requested the check or what follow up they would give, bearing in mind their patient had been found within the critical 72-hr post-discharge window with self-inflicted injuries, having consumed morphine.
Just prior to midnight, Michael sent a text message to another patient in the hospital where he’d been, saying he’d taken an overdose. That was made known to the ward staff but no request was made for the emergency services to re-attend. He was found dead at his flat around midday on the 2nd December in a tragedy which the Coroner has stated had involved failures by the mental health trust around discharge planning and care, including failures of communication and that it was specific failure the emergency services were not re-contacted after Michael indicated he’d taken an overdose.
VARIOUS QUESTIONS
I admit to having found Michael’s story difficult to read, not least because I would have loved more detail about various things:
- What was the basis of the ambulance service asking for police support? – for the avoidance of all doubt: it seems obvious police support was required and I was glad to read it was forthcoming and relieved to read officers felt entitled to force entry, presumably under s17 of the Police and Criminal Evidence Act 1984.
- The reason I’m interested in the basis for that support being given, is because we know we are entering a period where there will be greater scrutiny of police deployments to support healthcare interventions. There is no power for the police to force entry in order to conduct a ‘welfare check’ (Syed v DPP, 1998), but there is a power to enter to save life and limb.
- I’m interested in the basis for the decision by the paramedics to leave Michael at the flat and what, if anything, they did to ensure follow up if they had decided nothing was immediately required.
- I admit to wondering – and of course, I’m wondering this because I don’t have the detail – why no immediate intervention was thought necessary? Even if there was a basis for thinking the morphine consumption already complete by 11pm was nothing which would prove medically problematic, there must have been concern about what else could happen after #team999 left Michael’s flat.
- Given the difficulties there had been ensuring a post-discharge follow-up within 72hrs, I had to wonder when the next follow up would be and whether that would have been altered by the particulars of what the ambulance and police services had found when they attended and forced entry.
A really sad press release to read:
I will be curious to see whether the Coroner issues a Preventing Future Deaths report and whether that adds any detail to what we learned from Inquest. My condolences to Michael’s family, especially his mother who obviously tried her best to make the mental health system ensure her son’s care was appropriate.
UPDATE AUGUST ’24 – I can find no evidence of a PFD having been issued.
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
Mental Health Cop 