As many of you know, I’m currently wading my way through literally hundreds of cases of mental health (MH) police contact deaths (PCDs) with the aim of identifying as many as possible for my PhD research. Of particular importance to me is the Preventing Future Deaths notices which result from just over 50% of all MH-PCDs because analysis of those documents is what will feature largely in the final piece of research I produce for my thesis. There have already been a few posts about things I’ve found by doing this and the process is very far from over. Really, I’m only listing cases on my spreadsheet for analysis later in the year or next year.
One emerging point here is target of the PFD notice – the organisation(s) to which the notice is sent. A year or two ago I read the PFD for Michael Bray (Sussex 2023) and noticed it was full of criticism for police actions / inactions and one could easily imagine the coroner believing that unless those matters were address, it could lead to future deaths. Yet the PFD notice was sent only to the ambulance service. I’m aware Coroners sometimes do not issue PFD notices if the evidence heard recognises there were organisational failures which organisations acknowledge and commit to rectifying, if they haven’t already. Perhaps that’s what happened in Mr Bray’s case but it is nevertheless worth thinking about because there are other cases.
JASON PULLMAN
I was emailed this morning by a friend to make sure I was aware of a particular case and as it happens, I wasn’t. He gave me a link to a BBC News article which makes it known the parents of Jason Pullman are suing Sussex Police for alleged failings in their response to Jason going missing. I opened up my PhD spreadsheet to enter the details and looking for more information, like whether there was a PFD and there was. I immediately wondered if I’d missed that because I spent several days looking at the Chief Coroner’s website and going through every PFD linked to the “police” or “emergency services” which was also categorised as “suicide” or “mental health”. I’d missed the one about Jason.
As soon as I read it, it was obvious why – the PFD is targeted at an NHS agency about mental health care and the Chief Constable of Sussex Police is not even copied in for information. The police are barely mentioned, except for the possibility of Jason having been found on the railway network after going missing if BTP had been informed. Having read the news article on his parents’ allegations about police shortcomings which may yet to a civil trial, it was difficult to wonder whether I’m reading about the same case when reading the PFD. But I repeat the point: the Coroner may not always issue a PFD if they are satisfied from inquest proceedings those problems are in hand.
This has happened to me before, as well – you will remember last week, a police inspector was given a written warning in a misconduct meeting for failures around the risk assessment of a young man who absconded from hospital where he was detained under s2 MHA. When it was first made known on the BBC News that a misconduct processes had been directed after an Independent Office for Police Conduct (IOPC) investigation, it made me think any failings leading up to the young man’s death must have been police failings. But if you read the PFD, it is addressed only to the Priory Hospital and the Department of Health and Social Care. In this case it was copied to the Chief Constable, but that doesn’t obliged any response from the police.
HEALTHCARE BACKGROUNDS
We know that a lot of the cases coming up in my research have an express healthcare background – often including failings or omissions which contribute either to the death itself OR to the need for a police response after things deteriorate further, after those failings … or both. It then raises the questions for public perception about how these things unfold and where accountability should sit.
Last week in Nottingham, the inquest concluded after the death of Mr Kaine Fletcher in 2022. There was a really quite devastating conclusion for the state agencies involved and an embarrassing amount of evidence to suggest failings at senior and frontline levels. Right in there amongst all of that, however, was the revelation a street triage, or co-responder, vehicle had attended to Kaine just over 6hrs before the critical contact which led to his death.
Now to make a point I’ve made before after the deaths of Sean Rigg (London, 2008) and Seni Lewis (London, 2010) –
The fact there were healthcare failings of whatever kind prior to a police contact which went awry, by act or omission, doesn’t mean the police reaction can just be “well, if the nurse had acted correctly …” or “this wouldn’t have happened if health had done their job” or anything similar. Police exists as a social safety net for when primary mechanisms of social justice fail – it is literally the job of the police to run in after failings (of bars serving alcohol to drunk people; of bad road design; of NHS hospital who didn’t stop a patient leaving) and provide the appropriate response to that.
Whilst there is an argument to suggest the media are quick or over-keen to emphasise police failings and slow or under-keen to emphasise health failings, this doesn’t take us very far – and if we go back to the original point about PFD notices, it appears they may not always be doing as much as they could to ensure learning is concentrated where it needs to be: in the upper echelons of the police service.
Awarded the President’s Medal, by 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 