A new Preventing Future Deaths report from Greater Manchester is worth considering, following the sad death of Mr Michael Heath in August 2023. It was only issued this week following conclusion of an Article 2, jury inquest which examined Mr Heath’s suicide after a history of mental health contact and, crucially, emergency services contact in the days prior to his death.
Mr Heath was found deceased on 25th August at his home address in Trafford and five things contributed to his death –
- The police decision to close the incident log on 25th August without attendance.
- Poor communication between the agencies involved – don’t we hear this one in almost every multi-agency PFD?
- Failure of mental health services in Trafford and Gibraltar to communicate and a failure by Trafford’s mental health team to ensure the police were attending his home address on 25th August.
- Failure by North West Ambulance service to ask probing questions on 23rd August which led to a missed opportunity for face-to-face assessment (although the Coroner doesn’t say by whom).
- Michael’s own reluctance to engage with services, both mental health team and GP and his reluctance to take prescribed psychiatric medication.
NOT RCRP
No mention is made in the PFD of Right Care, Right Person and in fairness to it, Greater Manchester Police only began implementing the programme on in September 2024, more than a year after Mr Heath’s death. That noted, we can’t help but notice this is a PFD which emphasises a missed opportunity to undertake a welfare check – and welfare checks are No1 on the list of things to change when RCRP is introduced. There is no legal obligation on the police to undertake a welfare check, other than where duties under Article 2 or Article 3 are triggered by the relevant criteria being met – this is the immediate risk to life / immediate risk of serious harm stuff I’ve written about before. The Coroner’s PFD is not explicit in saying those criteria were met when the police incident log was closed on 25th August but we might wonder if he thinks they were because of his reference in the PFD to the police having duties to attend where there may be such risk and because of their powers to enter premises.
So, as ever: what does “immediate risk to life” mean to those answering 999 and 101 calls in the police, irrespective of whether RCRP is in play or not (because they law on this is the same, either way)? I’ve hinted in previous posts I’m not satisfied this phrase is being explained correctly in training for RCRP and I have specific and particular reasons for saying this because of information known to me. The most common way of getting this wrong appears to be to think that someone’s death must be ‘imminent’ for the A2 duty to protect life to be engaged and in my previous post on “immediate risk to life” I outline why this is not correct. It’s worth reading if you’re not already clear about it, and especially so if your job is to answer these 999 or 101 calls or make decisions about whether to ring the police.
One other reason for thinking about RCRP in this context where the force concerned did not have it in play, is because nothing at all prevents individual call handlers or police supervisors applying the legal threshold about what is and is not a police duty. This is what Dr Sarah Hughes, CEO of mental health charity Mind, called a “soft launch” in her evidence to the Health Affairs Select Committee in 2023 – the practice of starting to do “RCRP things” in forces where the programme has not formally commenced with partner organisations aware of it and prepared, at least in theory. Some have said forces shouldn’t be doing a ‘soft launch’ if partners aren’t ready but that’s a difficult one to comprehend because the corollary is to suggest forces should keep deploying inappropriately, with all the risk that entails, until such time as partners are ready – and we know from major initiatives like the Crisis Care Concordat they won’t be ever be ready, if we’re honest.
COMMUNICATION
In fairness to Greater Manchester Police, they’ve had their fingers burned before about not deploying to welfare checks because a previous decision of theirs to agree and which they subsequently passed to the ambulance service only to find it took many hours to deploy paramedics and the police still had to go anyway to force entry. On this occasion they declined to attend Mr Heath, closed their log and the Coroner has said this contributed to his death and is a “matter of concern” for the future.
Poor comms between agencies and between professionals within agencies have long been lamented as contributing to untoward events and it happened again here. Somebody, somewhere obviously requested Greater Manchester Police to undertake a welfare check (see point 1, above) but we can suppose (see point 3, above) there was an ongoing assumption by mental health services the police would undertake such a check, but they failed to ensure it was happening and / or GMP failed to explain it wasn’t. That, taken together with the failure of the ambulance service to ask more question (see point 4, above) and we have a recipe for people falling between two or more stools.
Even before we were using the letters “RCRP” we knew of cases where the police decline to undertake welfare checks – I know because I’ve been the police superivsor declining them. We also knew that some of those decisions would breach the duty of care owed, see the Sherratt case, linked above where GMP had a duty of care to act, mainly because they had originally said they would act, not because any legal threshold was necessarily met. But what I would have loved to see in this particular PFD was clearer articulation of what the jury found. It’s easy enough to speculate they were saying the situation on 25th August was an immediate risk to life, but is that, in fact, what they said?
It would be useful to know more and perhaps organisational responses to the Coroner by late November will illuminate this for us. I’ve set a reminder in my phone to come back and check but either way, this case is all kinds of sad and it won’t be the last time we read of such things.
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 am not a police officer.
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 