For a number of years now, emphasis has been separately placed on a couple of issues I would like to slam together and think about: police consultation with mental health services & mental health services’ risk assessments. You will remember, in 2017, the law was changed on the operation of section 136 Mental Health Act 1983, to state police officers should consult, where practicable, with mental health services ahead of using the power. Regular readers of the blog will also recall how I’ve contrasted the ways mental health professionals and police officers attitudes towards suicide risk differs and how we’ve seen that in the coroners’ courts.
The latest Preventing Future Deaths report to grab my attention is nothing to do with the police – it’s about the referral by a crisis service to secondary care mental health services of Mr Dean Ford in north-east London. Mr Ford died by suicide after the referral to services was rejected and the PFD tells us some interesting things about the rejection of the referral and gaps in the reasoning and information the trust held on him at the point of his death, because of that way that rejection was documented. For some reason, it made me wonder what would be said of him, if a police sought information about his mental health, either as part of formal consultation as part of s136 considerations or for any other reason.
DEAN FORD
Mr Ford suffered a decline in his mental health on the 1 March 2024, suffering from intrusive thoughts and his partner was concerned about him. She contacted the care crisis team in the very early hours of the 2nd March and Mr Ford spoke to them but they did not take a full history or carry out a full risk assessment. He was told he would be referred to the community mental health team and that referral was made but declined. The reasons for declining were not recorded or outlined in a letter sent to his general practitioner and no further information was sought from Mr Ford or his partner. He had a subsequent consultation with his GP and an appointment made for 20th March but on 10th, Mr Ford died by suicide.
It’s the nature of things in PFD notices the Coroners don’t outline much of the personal or wider background. This guy obviously had a partner and most likely more family than that and no doubt plenty of people are grieving his loss at the start of this year. He’d obviously struggled and it’s difficult to imagine what he went through having tried to seek support and what his family are now going through, especially after reading the PFD.
The Coroner had three specific concerns –
- Two teams involved in Mr Ford’s crisis care failed to assess the risk he posed to himself.
- The clinical lead’s statement of low risk was a “simplistic assessment” and not compliant with NICE guidelines. The Coroner added, “It is of concern that a senior member of the mental health team is not applying the correct risk formulation.
- The trust carries out risk assessment audits for patients accepted into the mental health and wellbeing team but there are no audits for those persons who are referred but declined. As these patients have no safety net of ongoing mental healthcare, it is of concern that the quality of risk assessments for these patients is not audited
POLICE CONTACT
Imagine another situation and the police encounter someone they believe to be vulnerable, depressed, possibly suicidal. Officers do their best to manage safety and contact the relevant professionals in their area to discuss options before resorting to s136 MHA. Someone picks up the phone and the police explain what’s going on and share the nominal information. Several minutes are spent whilst that nurse reads the background risk information held on the person with the officers.
Bearing in mind the chances of the nurse knowing the patient are slim and they obviously can’t see the patient to do a assessment of any kind, the best they can do is outline whether the person is known to services and give a sense of that background contact. In this case of Mr Ford, the nurse will only be able to say he presented on 2nd March with suicidal thoughts to a crisis team by telephone and referral was made for specialist support which was then declined for reasons that are not documented.
What does this mean to the officers: well, if a person is not accepted for specialist support after a proper referral from the NHS to secondary care services, one might wonder if it’s reasonable to think the person is low risk. How would the nurse summarising this or the officers know the risk assessment was dodgy and in breach of guidelines? … how would they know whether auditing of patients who are declined had flagged that and revisited the question of support? … how would they know the way things had been done was “simplistic”?!
COMMUNICATION
In a number of PFDs I’ve been reading recently, we come back to the issue of communication – it’s one of the most common themes in inter-agency failure: professionals not being clear with each other and working partially-sighted on the overall risk picture or context. It’s also been a feature for some years that PFDs for suicide after contact with mental health services suggest under-appreciation of risk. Families not listened to, patients not believed or as in Mr Ford’s case, the process of risk assessment – which we always must remember is an inexact science at the best of times – simply wasn’t followed according to national guidelines which aim to mitigate against human instincts.
It’s a been a feature on this website for years, that I’ve worried about police communication by telephone with mental health services to gain information about risk or to seek opinion about suitable options perhaps as alternatives to s136 MHA. This report, despite being nothing to do with the police, offers us new reasons to be sceptical – a trust making important decisions about the welfare of a vulnerable person in a “simplistic” way, against guidelines and then not only failing to document the rationale for rejecting someone’s referral after suicidal ideas but also having no audit mechanism to ensure those decisions are potential reviewed, or at least dip-sampled to ensure decision-making is sound.
All that can be said from outside, whilst acknowledging trusts vary, is: be careful what you’re prepared to trust and be aware of how blind some professionals will be to the wider picture and background because of what is not discussed or recorded in the course of some mental health care.
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
Mental Health Cop 