A new Preventing Future Deaths report from a London coroner after a mentally ill man from Leicestershire unexpectedly travelled to the capital and had contact with the NHS and the police before somehow entering the Thames and being found deceased. It’s a very sad case of considerable state and agency contact and it drew my attention because the Preventing Future Death report makes mention of officers determining use of s136 of the Mental Health Act 1983 was not either not necessary or not justified.
I want to explore that, given considerable detail in the PFD about events leading up to that conclusion by the police.
Michael Crane lived in supported accommodation in Leicester for those of us affected by our mental health. He had been diagnosed with schizophrenia, complicated by substance misuse, and he was subject to a Community Treatment Order which means he had previously been a detained patient under section 3 of the Mental Health Act 1983.
He was due to receive his next depot injection the day after contact with the NHS and the police.
Timeline
- At some point in the afternoon of 15th January, he was noted to away from home by staff and he had not returned by 2300hrs. He was not reported missing because occupants were free to come and go as they wished and he was considered low risk – policy was to report someone missing if they remain unexpectedly absent for 24hrs.
- Around 0554hrs on 16th January 2024, Mr Crane presented himself at to the Emergency Department in St Thomas’ hospital, London, having also spoken to Metropolitan Police Service officers. He was assessed by the Mental Health Liaison Team who decided nothing indicated he required admission to hospital under the MHA and the plan was to assist Mr Crane back to Leicester so he could have his depot injection, as planned.
- Around 0830hrs on 16 January 2024, the Home received a telephone call from the police to advise Mr Crane had gone to the Hospital. The Liaison Team also telephoned mental health services in Leicestershire.
- Shortly after 1155hrs on 16th January, Mr Crane was escorted outside by a member of staff in order to have a cigarette. He left and was seen to board a bus bound for Victoria station.
- No service had reported Mr Crane missing at this stage.
- At approximately 1640hrs on 16th January, Mr Crane approached two police officers on the Strand and asked if he was a missing person. Officers undertook some checks and advised him he was not and Mr Crane went with the officers to Charing Cross police station.
- The officers were aware Mr Crane had been at Hospital that morning and they also considered that he was dressed inappropriately for the weather, noting he referred to ‘hearing voices’. However, they took the view he was coherent and there were no grounds to detain him under section 136 of the Mental Health Act.
- One of the officers telephoned the Home, who advised that they had not reported Mr Crane missing but that they intended to do so in about 30 minutes’ time.
- At about 1730hrs, the officers noted that Mr Crane was becoming more and more anxious to leave the police station and they allowed him to do so. CCTV footage showed him leaving Charing Cross police station around 1730hrs and Mr Crane spent about 35 minutes in the general vicinity.
- His whereabouts thereafter are not known. At approximately midday on 18th January, officers from MPS Marine Unit retrieved a body from the river Thames, identified as that of Michael Crane, who was still wearing the wristband from his brief admission to the Hospital.
- At the time of retrieving Mr Crane’s body, the Home had not reported him missing.
CARE OR CONTROL
Last year, I was invited by a psychiatrists in a London mental health trust to talk to a joint group of NHS clinicians and Metropolitan officers about policing and mental health but the very specific request was about disentangling the distinction in the words “care” and “control”, within the definition of section 136 Mental Health Act 1983. The perceived problem leading to the invitation had been officers failing to realise the definition allowed for detention of a vulnerable person where it is not necessary to “control”, but merely to ensure they receive the right care and subsequently, vulnerable people who travel to London not being detained when the law might well allow for it, with obvious potential consequences.
Reading the PFD for Mr Crane made me recall that visit, ironically to London, to talk about that topic and I’ve written about this matter before. It may be useful to read that previous post before then considering what follows.
It struck me the officers believing they could not use their powers when Mr Crane was within them at Charing Cross police station be objectively correct and I want to look at this, especially as we all now live in an era where police involvement in mental health matters where there is no risk to life is being encouraged. Nothing in this situation screamed “immediate risk to life” for Article 2 purposes and yet here we are, wondering what can be learned from yet another Preventing Future Deaths report. We should keep in mind “immediate risk of serious harm” for Article 3 purposes.
The definition of s136 MHA is –
“If a person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons—
(a) remove the person to a place of safety …” etc., etc..
[Bold is my emphasis.]
OVERALL CONTEXT
What did we know in the afternoon of the 18th January about Mr Crane when he was at Charing Cross police station? –
- He was a resident of Leicester who had unexpectedly travelled to London.
- He’d already attended a London Emergency Department for support.
- He had left NHS staff there unexpectedly during a cigarette break – and the fact they felt the need to accompany him when he was subject to no legal orders might tell us something.
- He was not dressed appropriately for the weather.
- Services were in communication about returning him to Leicester, presumably because he had no way of doing this for himself?
- He was a CTO patient with schizophrenia, due to receive a depot injection the next day.
- Staff from his residential setting claimed they were due to report him missing within the next 30-minutes, albeit they did not do so – perhaps because they knew he was with the police in London at a police station?
So let’s walk our way through the “points to prove” of s136 MHA –
- Does this sound like someone who was suffering a mental disorder? – yes;
- Is he in immediate need of care? – yes (he’s dressed inappropriately for the weather, has no obvious way back to Leicester, has medication due which will not be received if not returned; agencies are already liaising about getting him back)
- Is this in his best interests? – quite arguably, yes! Otherwise who will the state (which now has a human rights duty to discharge because of contact whilst vulnerable).
- Is it ‘necessary’ – again, quite arguably, yes. How else are these things going to happen given he’s a double ‘absconder’, from his home and from the ED.
- The fact he was not in need of ‘control’ and that intervention was not necessary for the protection of others is irrelevant because we can see, above, the definition twice involves the word “or”, not “and”.
Of course, there may be more to the inter-agency discussions and other aspects of the inquest which go unreported in the PFD which mean it was absolutely the correct decision but the key point for this blog is not to take the PFD at face value when attempting to understand a context or circumstance which prevents use of the power – it doesn’t, based on what we see written down here. And if we remember what s136 ensures: it is about medical assessment by a doctor (who could, for example consider whether to offer the depot injection after speaking to Leicestershire’s mental health services) and assessment by an AMHP who could either formally consider the patient’s status or be involved in making necessary arrangements for their care.
HINDSIGHT
I’m conscious when reading this one we know Mr Crane died by somehow entering the Thames at the point where I’m wondering about the 136 decision and crucially, any decision to use the power does not guarantee another outcome. It may be the AMHP and DR who become involved, re-confirm what the ED liaison team thought was best and Mr Crane then walked from the s136 assessment and the outcome is unaffected or merely delayed a little.
But there are two points to make about that, without for a moment wanting to push defensive practices for the sake of covering one’s back. The first point is: it may have changed the outcome and police officers should remember, the fact some liaison nurses in ED think something, doesn’t mean you should assume an AMHP and DR think something else and the intervention interrupting what would otherwise have happened may, in fact, be enough to change the course. But the second thing is, we’re reading a blog on this because of the decision not to use s136 – I doubt I’d have written one if the power had been used and the outcome unaltered.
The police and the NHS have two different cultures when it comes towards risk mitigation and whilst it’s tempting to view NHS input as expertise, Coroner’s have had to caution against that in the past and officers have often found themselves pushing, nudging and agitating for reconsideration of NHS decisions, often appropriately. Rather, I’d encourage officers to do all they legally can to push towards the maximum chance people will be safeguarded.
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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