In June 2020, a quite appalling terror attack took place in Forbury Gardens in Reading – Khairi Saadallah planned a knife attack and attacked six men, killing three of them. A senior judge, sitting as Coroner, has now stated the deaths of James Furlong, David Wails, and Joe Ritchie-Bennett were “potentially avoidable” after the conclusion of an inquest this week. The judge highlighted various failings by a range of agencies, including MI5, Thames Valley Police and Berkshire NHS Foundation Trust.
It’s interesting to look at this sad case in the context of mental health and the courts system. When Mr Saadallah appeared at Crown Court he pleaded guilty to three murders and three attempted murders before being sentenced to a whole life order. At the time of sentencing the Crown Court judge said it was a “ruthless and brutal” attack and the victims “had no chance to react, let alone defend themselves”. He added it was “clear that the defendant did not, and does not, have any major mental illness”. You can read the full sentencing remarks from the criminal trial.
That seems fairly clear, doesn’t it? – no insanity defence attempted, no discussion about pleading guilty to manslaughter on the grounds of diminished responsibility not least because there was no psychiatric evidence which would justify either. He pleaded guilty to it all and was sentenced to life in prison. But we now need to look at the inquest proceedings just concluded to think about mental health in light of those comments – the inquest has been very interested in his mental health and the care that was received or not, sought or declined.
WELFARE CHECKS
We know Mr Saadallah’s brother rang the police the night before the attacks, expressing concern about his mental health and stating he thought the police needed to detain him under the Mental Health Act 1983 (MHA) because of a risk he may harm people – and keep in view, Mr Saadallah had a history of violent offences, including assaults on police officers. This led to a welfare check at his home address which was captured on body worn video, lasting just two minutes. It’s fair to say, the officers would not have had the power to detain him under the MHA, the encounter having occurred at his home address where police powers under s136 MHA cannot be used.
Media coverage about this also suggested officers had “failed” to find a knife which can be seen on the body worn footage. Bearing in mind they were there to conduct a welfare check (and standard warnings about officers undertaking welfare checks should apply) and that it’s not a criminal offence to possess a kitchen knife in your own home, it’s a difficult ask to think officers could or would have detained him for anything or seized the knife, if seen.
But the Coroner is clear: there were communication failings across this entire case and that includes the fact those officers were not told key information about the man’s previous levels of risk. They thought they were there because of mental health concerns which might involve the man harming himself and upon their arrival he assured them he was “alright”. Despite the brevity of the check (and the fundamental impossibility of them confidently establishing whether he was, in fact, “alright”), we can only wonder if it would have been done differently if those officers had been properly informed of the background and risk fears.
POTENTIALLY AVOIDABLE
The fundamental concern about preventability in the Coroner’s hearing, concerns mental health care for Mr Saadallah, the Coroner stating it was “at least possible” the attacks would have been prevented if there had been continuity of care. We know there were MHA related contacts for him: one of the attacks on a police officer, where he spat in an officers face, occurred during a MHA assessment where police were supporting other professionals. When these awful attacks took place, I distinctly remember reading coverage of it where it was suggested the contact with Mr Saadallah the night before the stabbings had been by a ‘street triage’ team (ie, police plus an NHS mental health nurse). I haven’t seen this point repeated on the coverage of the trial or inquest so I’m left wondering if the initial claim was correct? If anyone knows, please feel free to contact me.
But either way, there was significant police and mental health contact with him – and an obvious lack of communication across the agencies about risk. Only this week, I did an input for some university students and rammed this point home: almost all disasters where there are state failings, involve a lack of clear and accurate information exchange and we see it again here.
It will be interesting to note whether a Preventing Future Deaths report results from this, because I would be interested to see what the judge thinks the specific failures were. Reading the media coverage (links above), it remains unclear what specifically was being said. Easy to label the knife thing a failing, but officers conducting welfare checks do not have a legal right to search someone’s house for items which are lawfully possessed, unless there is specific allegation this amounts to an offence. I was also left wondering what those officers were expected to do, precisely. Is someone arguing they should have tried to convene a MHA assessment during the welfare check? If so, how realistic is that? – have you tried ringing the Approved Mental Health Professional (AMHP) service late at night to ask for a MHA assessment?
LESSONS LEARNED
As ever, there are already promises of action taken and lessons learned from senior figures in both policing and mental health. One thing I had to wonder about the welfare check issue, is whether the police would agree to do it at all, now we’re seeing the operation of Right Care, Right Person. Phase one of that programme means not undertaking mental health related welfare checks unless there is an immediate risk to life or risk of serious harm. Is someone’s brother ringing up to express a general concern someone’s health is deteriorating and that they may harm others going to be seen as a risk of serious harm?
Emphasis in RCRP seems to be about identifying the “immediate risk to life” criteria which would prompt so-called Article 2 obligations on the police or other state agencies – it’s highly unlikely those would be satisfied if it were a general concern something might happen. But what about the “risk of serious harm” obligation for Article 3? We know this is subject to less discussion than Article 2 stuff, so I probably need to do a blog post covering Article 3.
Ultimately and whilst acknowledging I can’t find answers in media coverage to some of the questions I have about all this and also that such answers may very well exist from the trial and the inquest, I am left wondering whether lessons will be learned – because I’m left wondering if they were understood in the very first place.
FURTHER MATERIAL
- Record of Inquest (James Furlong)
- Record of Inquest (Joseph Ritchie-Bennett)
- Record of Inquest (David Wails)
- Factual Findings
- Preventing Future Death report.
OTHER MEDIA COVERAGE
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, 2024
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 