In October, His Majesty’s Coroner for Sunderland issued a Preventing Future Deaths (PFD) report after the inquest of Mr John Hurst. It concerns mental health assessment in police custody, information sharing between the NHS and the police and, crucially, pre-release risk assessment by custody officers. Unfortunately, none of this is anything we haven’t heard before and it reinforces the importance of systems ensuring lessons are learned, rather than leaving such learning to individuals.
The PFD notice itself is worth reading – Mr Hurst was arrested for manslaughter by Northumbria Police on the 12th September after the death of his father. Officers had attended the sudden death report, made by John after an unexplained delay in reporting and found him in a vulnerable condition. They had concerns about his demeanour and there was what the media labelled “disturbing content” in some notes found in the address. The arrest having been made, he was promptly de-arrested for that, but subsequently re-arrested for possession of a controlled substance and taken to custody.
- Mr Hurst was then seen by liaison services from Cumbria, Northumberland, Tyne and Wear mental health trust (CNTW).
- Police officers dealing with him had raised concerns about his mental health and he had a history of schizophrenia and suicide attempts.
- Mr Hurst’s sister also raised concerns to the police about his potential suicide if he were to be released and she spoke to the liaison services who assessed him.
- CNTW believed he was fit to be interviewed and officers interviewed him then released him around 4pm on 13th September, speaking to his sister for the last time just before 10pm.
- He was found deceased on the 15th September, tragically.
INFORMATION SHARING
The crucial aspect in this case, according to the Coroner was the information sharing available to the custody sergeant who had to consider the pre-release risk assessment and take the release decision. The information which made it’s way to the custody records was highly partial and failed to mention much about the observations of the police officers who arrested him or the concern expressed by his sister about suicide after custody – it was in that context with the custody officer blind to some crucial information, Mr Hurst was released and died within 48hrs.
Information sharing is the issue of the century when it comes to multi-agency partnership working actually working – so many inquiries and inquests end up highlighting failures to communicate, inadequate documentation of decisions or rationale for decisions or just a plain failure of professionals to exchange information, including between organisations or, as in this case, within organisations.
Liaison and Diversion services in police custody have been a well-entrenched thing for over a decade now and they’ve existed in embryonic forms for as least another decade or more. What I’ve never found to be settled and solid, is the overlap between NHS and police responsibilities and we see some of that conflation here.
FIT TO BE INTERVIEWED
The decision about whether someone is fit to be interviewed is a legal matter for the police, ultimately for the custody sergeant. Of course, where a clinician is assessing someone with established and known vulnerabilities, clinical records may assist in ensuring the nurse’s view is influenced by the person’s clinical background. But ultimately, in law, the decision about fitness to be interviewed is one for the custody officer – not the liaison and diversion service.
Thinking about broader issues in custody with L&D, I was reminded of His Majesty’s Coroner for Birmingham and specifically remembering another inquest where officers had deferred to liaison and diversion services because of them being “experts”. This was a word the Coroner went out of his way to dismiss when issuing his own PFD for that particular case, a homicide.
As the country and it’s various forces and trusts go about the business of reframing their partnerships and relationships around policing, mental health and criminal justice, it’s the crime investigation domain which arguably requires the most work in the future – ironically, the very domain of police activity officers insist is the very raison d’être of the police.
Still so much to do – and communicating well is at the crux of it all.
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 