The death of Sebastian Oliver, known as ‘Benji’ in Birmingham in November 2023 was an accidental death following significant blood loss and hypothermia after an injury to his left hand whilst under the influence of drugs, according to His Majesty’s Coroner for Birmingham and Solihull. There was significant emergency services contact prior to his death and debate about the conduct of ‘safe and well’ checks on people thought to be vulnerable or in need of follow up.
- Mr Oliver was found cold and non-responsive by a member of the public in Sutton Coldfield around 0621hrs on 29th November 2023 and an ambulance was called.
- He was suffering significant blood loss from an incised wound to his left hand, together with hypothermia. Paramedics conveyed him to Good Hope Hospital where he could not be resuscitated and he was pronounced deceased at 0756hrs.
- The evidence indicated no third party involvement and he appeared to have impaled his left hand trying to climb a spiked fence whilst under the influence of drugs.
There was background contact with West Midlands Ambulance Service the day prior to him being found unresponsive and ‘contact’ with both Good Hope Hospital Emergency Department and West Midlands Police but for some reason, the Coroner has issued a Preventing Future Deaths report only to West Midlands Police, but copying in the others which does not oblige them to respond.
- Mr Oliver was attended to and treated by WMAS paramedics twice during the evening of 28th November, the day before he was non-responsive – the precise details of these encounters are not outlined.
- The first paramedic crew deemed him to “have capacity” (whatever that means) so when he declined treatment, he went on his own way despite some degree of intoxication.
- The second deemed him to lack capacity (whatever that means) but he did agree to be conveyed to hospital, from where he subsequently absconded.
- HM Coroner did crucially state in the PFD: “It is not possible to say whether he would have been found following absconding from hospital” but there were “missed opportunities” which on the balance of probabilities these delays did not minimally, trivially or negligibly contribute to his death.
SAFE AND WELL CHECK
HM Coroner lists seven “matters of concern” (MoC) but it is difficult to tell whether each of them individually is a specific concern and they certainly don’t all relate to WMP. For example, the first states –
1. The evidence heard at inquest indicates that following an emergency call at 2218hrs on 28th November ’23, paramedics from West Midlands Ambulance Service (“WMAS”) assessed Mr Oliver as requiring hospital treatment to his hand but he refused. Although he was intoxicated, he was deemed to have capacity and let about his way. “
So is the coroner saying assessment of capacity is a matter of concern and, for example, he should have been assessed as lacking capacity? It’s hard to tell from the wording.
The second states –
2. At 2310hrs on the same night, paramedics attended upon him a second time and deemed him to lack capacity due to intoxication. He agreed to be conveyed and treated in hospital but when paramedics went to handover to the hospital staff, he absconded at 0041hrs on 29th November.
You will notice so far, these are both matters for the ambulance service but you’ll remember from the introduction to this post, the PFD has been sent only to West Midlands Police who cannot possibly be expected to comment on either of these first two matters because they relate to issues for WMAS and the paramedics involved. The PFD was sent for information to WMAS, but that does not oblige them to respond to it.
POLICE ISSUES
The third MoC is –
3. WMAS notified West Midlands Police (“WMP”) and requested a “safe and well check”. After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
And the fourth point is key for me, in this PFD –
4. However, the decision to close the log was an error – as a person’s capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a “safe and well check”.
The fifth MoC isn’t an MoC at all, it is an observation or finding by the Coroner –
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital. before being recorded on CCTV at 02:55 at [REDACTED], and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
But the sixth MoC is something which bears discussion for reasons outlined in the seventh and final point –
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver’s capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a “one-off” issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
DECISION TO CLOSE THE LOG
This point in bold in MoC 4, above, is my emphasis – the Coroner did not use bold to ram home a point but the claim of an error is significant because it’s alluding to something objective. West Midlands Police had introduced the Right Care, Right Person scheme by late November 2023 so call handlers would, like in so many other forces, have been operating to the procedures put in place. Regular readers and those familiar with the scheme will know that RCRP suggests requests to undertake welfare checks will only be accepted if there is an immediate risk to life or risk of serious harm. In the scenario we learn of, above, nothing suggests the life-threatening threshold is met until we learn Benji was non-responsive in the street on 29th November at 0621hrs so it’s potentially the case that RCRP processes would have contributed to declining to undertake a welfare check.
So for me, there is stuff missing from this PFD in terms of helping us understand what has gone on here. The first point is no mention is made of RCRP at all despite the programme being in place when the incident occurred and regardless of the programme, any request for a safe and well check needs to be considered for whether it is, in reality, a missing person. In this example, the PFD does not tell us whether Benji’s home address was known or the precise details of the two WMAS contacts on the 28th November – was he encountered at home or in public; where do WMP actually go to check on his welfare, if they accept a need to do so? And even if his home address was known, the point of concern was him leaving hospital after being conveyed there “without capacity” by paramedics. Nothing could make it certain he had, in fact gone home unless the home address is checked.
Capacity is also a problem throughout this report, not least because “capacity for what?” The WMP decision to close the log was taken, according to the PFD, due to Benji having capacity, presumably because that’s what was stated in the first WMAS contact on 28th November. But the second and more recent contact, said the opposite and the Coroner is right to point out, capacity can (and does) fluctuate, esp where intoxication is concerned so it would be a little weird to rely on something less recent as the basis for a decision. In case you are not aware, the Chief Coroner’s website, to which PFD notices are uploaded after issue, often contains responses from the organisations to which they are sent. West Midlands Police has responded to this PFD –
POLICE RESPONSE
There is more detail in the police response and it does address some of the question I had reading the PFD, but not all of them. It is a lengthy response and you have to dig deep for the detail relating to Mr Oliver’s case but the punchline in this:
- The person closing the log did not document an adequate rationale as to why they closed it and, specifically, did not utilise the so-called “THRIVE” methodology to assess or re-assess risk.
- Following the introduction of RCRP in WMP, no action would have been taken anyway in terms of a concern for Mr Oliver’s welfare after he left hospital.
- Any consideration of treating Mr Oliver as missing would have involved WMP asking the reporting hospital or WMAS to complete their own “reasonable steps to locate their patient as per their statutory obligation”. For example, through repeated attempts to contact the patient, their next of kin and through dispatching an ambulance to the reasonably suspected location of the patient such as a home address.”
There are various discussion points here and we don’t know whether these were discussed at the inquest or not.
THINKING SOME THOUGHTS
- Firstly – because the person closing the log did not document a rationale, we do not know what factors they took in to account, beyond the earliest assessment that Mr Oliver “had capacity”. WMP itself accepts was it was wrong not to document a decision and wrong to rely upon the first assessment of capacity when the second was also known about and more recent.
- Of course, nobody in the PFD or the WMP response is asking themselves “capacity for what?” – capacity, as we know from elsewhere on this website, is not something you have or don’t have. It is decision-specific, context-specific and the WMAS assessment of capacity – presumably, to accept or decline care from the ambulance service – is not necessarily the same things as capacity to decline care or treatment offered by an Emergency Department who, for all we know, didn’t have time to assess capacity in their context, because Mr Oliver is reported to have walked off during handover.
- It is a very common problem in policing and healthcare to hear professionals talking in absolute terms, saying things like “He lacks capacity”. Well, unless he’s literally unconscious, he doesn’t necessarily lack capacity for everything and considerations around invoking the Mental Capacity Act to keep people safe should be in accordance with the act – ie, context and decision-specific.
- Secondly – suggestion that article 2 or article 3 risks were not met: well, nothing here screams life-threatening, but he was described by WMP in their response to the Coroner as being intoxicated through opiates. We don’t know the precise circumstances in which WMAS found him, we don’t know if he had further access to opiates and we know he’d wandered off in to the night.
- We also know from other law and from other inquests in the WMP area that Coroners have had to point out, agencies should be talking to each other, doing their own background checks and so on, before reaching decisions about assessment of Article 2 or Article 3 rights. You don’t just listen to the WMAS call or ED call and then say “oh, had capacity three hours ago so we’re not attending”. You do due diligence to establish as much as you reasonably can before taking a decision which may impact on someone’s life.
- Finally – the issue again of “reasonable steps to locate their patient” – we don’t know whether WMP are saying this because there were actual steps the ED or WMAS could have taken. Did they have a mobile phone number for him – we don’t know; did they have any next of kin details for him – we don’t know; did they have any location to which they could have sent an ambulance to enquire after him – we don’t know.
- And something crucial about this last point: ambulance services don’t send valuable resources to provide patient care at a location where they do not yet know there is a patient so I’m keen to learn more about the “statutory duty” WMP think WMAS and the ED have. Yes, they also owe a duty of care to their patient but nothing in the PFD or police response tells us they did have actual enquiries they could reasonably have undertaken when it might well be argued Mr Oliver was a missing person whose location was not known.
- It also fails to recognise the ED and WMAS are two separate organisations – it is not up to ED to determine how WMAS spends its resources and WMAS might argue they discharged their patient duty by conveying him to ED.
So I have many more questions about this case now I’ve read the police response than I did after only reading the PFD and one version of what might have happened here could be – given both documents taken together: a man who lacked capacity to decline ED care and who was vulnerable and at risk whilst intoxicated through drugs walked off from an ED where article 3 obligations were met but where ED simply did not have reasonable steps available to them to locate him and the police declined to respond to a missing person.
If that’s not what happened here, I’ll need more to satisfy myself and whilst the Coroner can’t say these decisions “minimally, trivially or negligibly contribute to his death”, we also can’t say they didn’t – MoCs 6 and 7 make it worth knowing the detail because I think it is a “larger or institutional issue”, given my experience.
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, 2025
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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