Some Preventing Future Death (PFD) reports on the Chief Coroner’s website are a little frustrating because they don’t always give a full explanation of what has gone on and don’t necessarily make full sense we read the circumstances of death and then look at the matters of concern.
In case you’ve not looked at them too closely, a PFD notice follows a format and the Coroner issuing the notice must complete the various sections. Having a read who-knows-how-many of these things, there are very different styles and approaches in terms of length of notice and the amount of narrative within. Of course, the overarching purpose of a notice is within the name of them – to prevent future deaths – so I’ve always wanted to see enough explanation of events to make sense of what His Majesty’s Coroner is saying is a “matter of concern” in that particular case – and we usually do see this.
In the particular case of a recently published notice, the sad death of Mr Michael Bray in Suffolk, there is a limited description of circumstances which gives rise to a lot of questions but then, only one real matter of concern raised. There is no media coverage I can see, to help outline the story any further.
AMBULANCE DELAY
Mr Bray died at his home address at some point overnight on 10th October 2021. Unfortunately, there was not enough evidence before the coroner or jury to determine everything an inquest seeks to clarify and a conclusion of misdadventure was returned.
The sad timeline of known events appears to be –
- Initial contact with a mental health crisis team prior to 2am in a phone call which he eventually ended.
- The crisis team then contacted Suffolk Police and requested a ‘welfare check’, a request which was declined for reasons which are not explained at all.
- It seems the police were told during that contact that an ambulance had been requested by had indicated there would be a 2hr delay, at least – this doesn’t appear to have changed the decision not to attend.
- It appears ambulance did not request a police deployment for over an hour after they were contacted, something which was not made clear to the ambulance despatcher.
- There is mention of the ambulance service arriving at an unstated time and declining to approach the property, for reasons which are simply not stated.
- The delay in the ambulance service then requesting the police to attend after that decision.
- The decision of the police not to conduct a ‘welfare check’ after that initial crisis team contact was described by the Coroner as a ‘failure’.
You might think then, the matters of concern in the PFD notice would include somethings about the police service and the ambulance service, notwithstanding that the various references in the bullet points, above, were not fully explained. Why was the police decision not to attend a failure? – why did the ambulance crew not approach the property?
LEARNING LESSONS
HM Coroner for Suffolk as sent is statutory notice to the Secretary of State for Health and the Chief Executive of the East of England ambulance service however it was only copied to the Chief Constable for his information, not sent to compel a response from the police. The Coroner was at pains to stress his concern about the ambulance service response was not just a local concern, but one reflected nationally – hence he sent this primarily to the Secretary of State for Health.
If the purpose of PFDs is to ensure lessons are learned, not just by the organisations involved in the particular case, but also by other ambulance and police services, it would be extremely useful if the public documents had sufficient detail to make it obvious why certain things were claimed in the description of circumstances.
This is especially the case now we are in the Right Care, Right Person world.
This PFD was actually issued in May 2023, a full year before it has been loaded up to the Chief Coroner’s website and a lot has changed in a year. Suffolk Police launched the RCRP programme in their force area in April 2024, something which was a point of debate amongst the various candidates for Suffolk’s Police and Crime Commissioner ahead of the recent election. Phase 1 of RCRP is always to look more carefully at requests to undertake welfare checks so it’s especially timely to think about this PFD notice in that new context.
IMMEDIATE RISK TO LIFE
The criteria for police deployment to a welfare check is whether there is an “immediate risk to life” (IRTL) which is “present and continuing”. We do not know from the PFD what the Crisis Team said about Mr Bray when they rang the police around 2am and we don’t know what was known by the police already about any history involving Mr Bray which would influence whether someone might think the IRTL criteria were satisfied. The labelling of the decision not to attend as a ‘failure’ is interesting in that context – is the Coroner saying the police were under an obligation to attend or not?
It’s a shame we can’t know and we might have to assume they were not under an obligation otherwise we may see the PFD going to the Chief Constable with this issue listed as a ‘matter of concern’. If it was not a matter of concern because of there being no obligation to attend, is it fair to describe it as a ‘failing’ in the first place? – it’s such a shame we have to guess at this when it may be relevant to the general issue of welfare checks and it may illuminate how some coroners are looking at this, bearing in mind there are other inquests pending since RCRP was introduced where welfare checks have been declined or delayed.
If we really do want services to learn lessons and ensure they are shared nationally – especially at a time when new programmes or work are changing established cultures and practices – more detailed PFDs or other material to help us fully understand the detail of what happened is absolutely essential.
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 