Last weekend The Times newspaper published three articles about the Right Care, Right Person programme – it’s fair to say the immediate social media response to that was interesting, including a Chief Constable going off the deep end with reaction to a case he obviously hadn’t understood. I’m stating that somewhat confidently because if he had understood the case he was commenting on, his remarks would be even more outrageous.
I’m trying to give him the benefit of the doubt but “We are no doing this anymore” in response to an article highlighting a case where even the police force involved admitted they got it wrong, was a real low point for me.
I wrote a blog last weekend about “Losing The Argument” on this and decided a small break from blogging might just help me think a few things through, not least because all this stuff about police contact deaths is the stuff of my PhD research and as the new academic year begins and after a supervision meeting this week, I’ve got plenty of work to do on that – albeit not just RCRP specific contact deaths. But then I did an end of the week check on the Chief Coroner’s website and there’s another one to trouble us.
CHARLOTTE TETLEY
In January 2025, Charlotte Tetley died on the Cheshire Coroner has issued a PFD notice – the first for that force linked to RCRP. Charlotte had a long, complex and sad history, all which of which appears to stem from her being a victim of the Rochdale grooming gangs where she suffered significant sexual abuse. She had moved to the Cheshire area after her abuser returned to her original home area. The PFD contains detailed history I’m not going to go in to here, suffice to say there was a lot of stuff about mental illness, suicidality and the potential need for hospital admission to keep Charlotte safe – and there is actually a second, separate PFD issued to the mental health trust (which doesn’t add anything to the point I make here or the detail in the first PFD to the police).
Then, on 18th September 2024 she was found on railway tracks and then removed from them by British Transport Police who took her to an Emergency Department. I’d love to know more about the decision-making here – trespassing on the railway line is a criminal offence; section 136 of the Mental Health Act 1983 can be used on railway lines so the officers had two different powers of detention to choose from but did not detain Charlotte under either provision. Having attended the ED, the PFD reads as if they left her there and that’s interesting when you consider the detailed history given by the Coroner. Fair enough, I wasn’t there – but I was left wondering why she wasn’t detained for an assessment under s136, because one thing you’d worry about after Charlotte’s history, was whether she would remain in the ED if left there unsupervised?
She left there, having been unsupervised – and later ended her life on a railway line on the 24th September so one legitimate question may be, if she had been detained under s136 MHA and received a MHA assessment, might she have been “sectioned” on 18th of September or soon afterwards and been unable to attend a railway line on 24th? We’ll never know.
Right Care, Right Person
The PFD however, details what happened when the ED called the Cheshire Police after Charlotte left their department on 18th September –
She was reported by the NHS to be a “high-risk missing person” but the police stated, under the RCRP policy, nobody would be deployed. An NHS clinical lead escalated this to a supervisor and expressed concerns about an immediate risk to Charlotte’s safety but was told “as Ms Tetley had not voiced intention to end her life, it could not be known that this was her intention when she left the department”, (which is hardly the point). Despite further emphasis Charlotte was not engaging and the concerns for her immediate safety were real, the police maintained nobody would be deployed and suggested the ambulance service should go out.
And yet again we have to wonder:
Where, precisely, did the police want the ambulance to go, given no-one knew where Charlotte was?!
This is, I must insist, pretty basic stuff – it’s well known the ambulance service do not spend resources searching for missing people. Yes, if an injured person is a small area like a local park, they’ll go to the park and look but if someone is known only to be in a large area like “Macclesfield” or “Cheshire”, why would they expend resources on that when it means ignoring 999 calls for heart attacks and so-on? We have decided as a society the police undertake searches for missing people where the risk is sufficient to worry, as it was here, and College of Policing guidance on missing people confirms this – it’s not ambiguous.
ONE BIG THEME EMERGING
And here we are again:
A new PFD, telling us the police did not recognise clearly-stated risk being articulated, in this case by NHS professionals with insight in to the history for a particular patient. The control room staff did this not once but twice, apparently applying a very narrow (and incorrect) definition of “immediate risk to life” which resonates with the explanation I saw in RCRP training several years ago and which I escalated has being wrong and overly narrow years ago. Ultimately, they attempted again to deflect a job to the ambulance service which it should have been known they ambulance service would not accept – and I admit to thinking they would be quite right do decline because they have no patient to treat, because they are unambiguously missing and at serious risk.
I wonder how many near-misses and non-fatal outcomes there are where the decision-making about vulnerable people was similar but where it was never highlighted as wrong because no-one died? Remember, the College of Policing say risk-based decision making isn’t judged by the outcome, but by the quality of the decision-making – it’s in principle 4 of their risk principles.
So the scores on the doors are now standing at –
- 18 completed inquests which I argue are RCRP inquests
- 16 Preventing Future Death reports
- 14 of which mention RCRP, the other two are relevant because of RCRP being cited by the police force concerned in their response to HM Coroners.
- I remain unclear the two inquests did not lead to a PFD – both seemed to justify it.
There is now an obvious theme running through many of these PFDs and inquests – under-recognition and under-response to obvious, stated risk, inappropriate deflection to the ambulance service and ultimately, a lack of support to a vulnerable person. This is what comes up in, from memory, 10 of the inquests so far and all of this despite the National Police Chiefs Council lead on mental health, Chief Constable Rachel Bacon from Durham Constabulary, insisting the police will “always respond” if there’s an immediate risk to life – despite the evidence that her own force didn’t after the death of Sophie Cotton and neither did a list of others, to which we now add Cheshire Police after Charlotte’s death.
Always remember — warnings were given that exactly this kind of thing would happen, they were ignored and when The Times challenged the force which ignored them, they ignored that as well and instead issued a generic press release telling us nothing new and saying this makes things better, despite the fact it simply has not been evaluated. I’ve no doubt it does make things better, in some cases, but at what cost?
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 