There were “missed chances, confusion and errors” in the care of a Huddersfield dad who took his own life, according to His Majesty’s Senior Coroner for Huddersfield, Mr Martin Fleming who also described organisations’ responses to Martin Waite leaving an Emergency Department as “lamentable”.
Mr Waite had a history of mental health problems and was under the care of his local mental health trust when he took an overdose at home on 29th October 2022. He was taken by ambulance to Royal Huddersfield Infirmary where he was treated and assessed. It was agreed he needed psychiatric admission but there was no bed available and he agreed to remain in an ED cubicle overnight, or until one could be found. At 5:37am on 30th October, he left ED for the second time, having already left once and returned after visiting a motorway bridge. He was then reported to the police as a high risk missing person and at 6pm – over 12hrs later – officers forced entry to his home and, sadly, found him deceased.
The coroner had various observations to make, as did Mr Waite’s family. He had previous attempted suicide and had jumped from a moving ambulance; the observation was made that supervision overnight in ED was inadequate and there was a missed opportunity for one-to-one care. Furthermore, the ‘lamentable’ aspect of the emergency services’ response to him being reported missing, was the handling of the question of whether police or ambulance would undertake a “welfare check” and what local protocols about missing people or patients said.
Who had a duty to “knock the door”?
CONFUSED
At the end of the local news coverage of the inquest’s conclusion, I couldn’t help but notice the update that West Yorkshire Police (WYP) have ensured further training on the meaning of “immediate risk to life” and this might give us a clue about what has gone on here. Last year, I wrote a whole post about the legal phrase “immediate risk to life” because I was concerned based upon what I’d seen towards the end of my police service, that it wasn’t well understood. In summary, the training materials to which I was privy defined it incorrectly and they did this by narrowing the scope too far, meaning there was scope for staff to deploy their training and declare something was not an IRTL when in fact, it was. The news coverage in Mr Waite’s case doesn’t help us understand whether this is what the Coroner found, but the fact the police then provided “further training” on IRTL gives us a clue.
Of course, Mr Waite had been reported as a high risk missing person – I would have loved to know whether the police treated him as such because on the face of what we can read here, he was. That it then took over 12hrs to put someone through the front door of his home address to search for him seems odd – it would be one of the first enquiries you would do for a high-risk missing person if they had left hospital in circumstances like this. HM Coroner Martin Fleming said the two organisations were unclear about their roles and doing the ‘Hokey Cokey’ regarding who should knock on the door but he was unable to say whether this would have made a difference in Mr Waite’s case, if the confusion had been avoided.
This is what concerned me about this case – and I’m concerned irrespective of whether West Yorkshire Police were implementing the Right Care, Right Person programme or not. Various points to make on this –
- The conduct of welfare checks is phase 1 of RCRP, so it’s in place in almost all forces – I heard yesterday that 42 of 43 forces in England and Wales are now live with at least some of this programme, but it’s subject to the caveat of whether there is an ‘immediate risk to life’.
- In this case, Mr Waite was reported as a high-risk missing person which is a good clue the hospital thought his life may be at risk and the fact West Yorkshire Police have issued remedial training and advice, suggests they may accept it was an IRTL situation not correctly assessed as such.
- This is not the first incident which is destined for a coroner’s court where the police have pushed a welfare check to the ambulance service, only to later decide to do something which suggested the initial assessment of no IRTL wasn’t correct.
Whether or not WYP and YAS were working to anybody’s approach to RCRP is not the point –
- If they weren’t – it just emphasises the importance of ensuring effective training and partnerships before these programmes begin
- If they were – it emphasises the importance of ensuring effective training and partnerships when these programmes begin.
ATTENTION TO DETAIL
Yesterday, the College of Policing hosted a public webinar about Right Care, Right Person on behalf of the National Police Chiefs Council and Rethink Mental Illness. It was a four-hour event where we heard from police, ambulance, mental health providers as well as people with lived experience and so on. There’s no way to avoid it: the event was quite disappointing and I left feeling more confused than when I began having heard some quite concerning things, presented as positives. It was useful to learn we should see some evaluation of RCRP from the Home Office and Department of Health and Social Care soon, potentially by Christmas.
But it was quite concerning to realise that various senior people think RCRP is about different things. I was quite surprised to find one introductory talk was just describing RCRP, including the “threshold” and its four phases. Then we heard from Lisa Townsend, the lead Police and Crime Commissioner for mental health whose own organisation’s guidance says RCRP is about different things to the original programme in Humberside or the National Partnership Agreement and by the end of event, we heard from an NHS professional telling us that RCRP was not just about mental health – it was about “everything!”
What we heard little about was the kinds of things that go wrong in cases like Martin Waite’s: the decision-making which is going on in police control rooms and between organisations who are trying to do basic partnership work. We know there has been mission creep with RCRP, we know other inquests are pending and my sense of it is the longer the police and NHS are having extensive get togethers where those kinds of things are simply not discussed, the more people will come to harm until eventually something forces the discussion. I can’t help but feel, even if HM Coroner for West Yorkshire (West) is satisfied that WYP and YAS have properly responded to the obvious questions and even if local protocols are clarified, there is obvious potential for these kinds of things to happen elsewhere in England – we know there is, because we know other inquests are pending. So I can admit, I’d have liked to see another Preventing Future Deaths report in this case, accepting the problems with the whole PFD system in the absence of a national oversight mechanism, as called for by the charity Inquest.
The question I asked in yesterday’s webinar (which was not addressed) was –
“If I were to suggest RCRP decision-making by police forces has contributed to loss of human life and it offers potential for more not least because of problems with the training given: What would you tell me to reassure me I’m wrong?”
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
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