In January 2022, Mr Robert Young twice rang 999 in distress and sadly, died shortly afterwards by suicide after the police and ambulance services were calling each other about the incident. Counsel representing Mr Young’s family at the inquest persuaded the court that Article 2 of the European Convention on Human Rights was engaged in this case, leading to critical jury findings of the way in which the incident was handled by both services.
TIMELINE
- Mr Young, who was forty-two, died in the early hours of 30 January 2022 having made the 999 calls, both of which were cut off before he spoke to the appropriate service.
- The police returned a call – standard procedure for cut off 999 calls is that they go to the police – and Mr Young stated he wanted an ambulance, not the police and expressed a desire “not to be resuscitated”.
- He also stated he “did not wish to live anymore” and when asked whether he was going to “do anything silly”, he refused to answer.
- Police officers were dispatched towards him at 0335hrs.
- During a subsequent call with the ambulance service, he stated further he did not “want to be brought back to life” and stated “do not resuscitate me, I don’t want to live”.
- He was told “If anything gets worse or changes call us back”, which I admit to thinking strikes me as a very odd thing to say to someone who has declined an ambulance with an instruction not to resuscitate …
- A police officer asked to look at the incident considered it was a matter for ambulance service which did not require a police response.
- The ambulance service was contacted and asked to respond to the incident.
- During that call, the police said they had been asked to attend but in a further call the police did not make clear they would not be attending, only that they needed to ‘pass’ ambulance a job.
- The coroner highlighted this is informal language that doesn’t mean anything precise – does it ‘pass’ mean “it came to us but it’s only for you” or does it mean “it came to us and we need your help so can we both attend”?
- It wasn’t clear at all.
- Paramedics arrived around 0356hrs but were unable to gain access and were expecting police attendance.
- They requested an update on the ETA for officers it took until 0405hrs to learn the police had taken a decision to cancel.
- They tried to look inside the house and saw Mr Young requiring urgent attention so they forced entry to the property themselves and started resuscitation.
- Mr Young was pronounced deceased at 0447hrs.
The jury made the following findings –
- Inadequate information about Mr Young’s identity was gained from the initial 999 call between Mr Young and the police call handler, meaning that Mr Young’s history of suicide attempts was not recorded on the police log relating to the incident.
- The release of the police officers from the incident involving Mr Young and dispatch of those officers to another incident before a supervisor had reviewed the decision was inappropriate.
- A difference of ‘interpretation and understanding between police and ambulance services’ regarding what it means to ‘pass’ a job to ambulance services led to confusion about whether police would be attending the incident involving Mr Young.
- The initial call back from ambulance services to Mr Young was inadequate as it failed to identify any personal details of the caller, therefore the ambulance incident log was closed without further action requested from ambulance services.
VARIOUS IMPLICATIONS
It’s not yet obvious whether there will be a Preventing Future Deaths report for Mr Young’s inquest – at the time of writing, none has been published on the Chief Coroner’s website and the press release from Doughty Street chambers makes no mention of it. But the obvious point to make here is that call handlers, officers / paramedics and their supervisors may need a more detailed knowledge of what an “immediate risk to life” actually is – we already know there is confusion about this in addition to the confusion highlighted by the coroner about the use of the word ‘pass’.
Perhaps inevitably, it made me think about Right Care, Right Person although I should be clear: this incident pre-dates the force in question introducing the RCRP programme. It made me think of it, however, because we know the police are now stating they actively work to a threshold hold of “immediate risk to life”, which is the Article 2 threshold. It’s clear the Coroner and jury thought there was an arguable case that A2 is engaged in this incident. Coroners’ conclusions never involve a clear declaration of A2 breach or not: the jury is just asked to reach factual conclusions about what happened and to answer questions from the Coroner if required. It would require a civil action to formally establish whether A2 was violated and in this case, to determine whether it was police, ambulance or both who owed or breached such a duty, where owed.
All that said, the confusion across 999 here is obvious: and it seems both organisations had struggled to satisfactorily justify their part in the response here. On the one hand, you could say, “someone in a healthcare emergency rang 999 for help – that is for the ambulance service unless there is a clearly defined policing purpose. Can we identify one?” Well, on the one hand there is the question about forcing entry to premises – the police have obvious statutory powers to do that and whilst it’s entirely possible to fudge an argument the paramedics could legally justify it as well, the normal route to thinking about forcing entry to people’s private homes is the police service. On the other hand, for what reason might we anticipate entry would be refused? – Mr Young had rung 999 himself, telling the police he wanted the ambulance service and the ambulance service did then respond so is there a A2 duty on the police? Well, they did not inform the ambulance service they would not attend until after the situation revealed entry was a problem …
SYSTEMIC MISTAKES
… it’s all just such a mess, isn’t it?
Probably needs us to know more detail than we are seeing in the Doughty Street press release to fully understand things, hence I’d be keen to see any PFD notice or record of inquest which may be published. I will keep checking for them.
Meanwhile, we know the police role in responding to “welfare checks” is a developing picture and we know of other PFDs from the pre-RCRP era show the kinds of complex difficulties we can find when we have to start untangling things. I can only imagine we will see even more untangling of this kind of thing in the RCRP era as we already know police forces are “passing” incidents like this to ambulance at a higher rate than before – 200-250 cases a day in London alone – and we know one inquest is already pending which will test how approach survives contact with the expectation of the courts in ensuring the safety, the dignity and the rights of vulnerable people.
I can only hope we don’t simply see the kinds of criticisms we have already seen about these isolated incidents becoming systemic problems because of how leadership, governance and training for the programme has been done.
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
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