The latest PFD to mention “Right Care, Right Person” was published this week, after the death of Catherine Morgan in Kent in September 2024. The PFD is primarily about the Metropolitan Police, however, as Catherine went missing from a south London mental health before travelling to Dover where she died by suicide as police officers attempted to persuade her to safety.
The PFD uses the phrase “overly rigid” no fewer than four times, to describe how RCRP guidance was applied to the situation being handled because of Catherine’s circumstances.
In brief –
- Catherine left the mental health ward at 1030hrs, her first period of unescorted leave.
- She had agreed to return by 12pm but it was only noticed she had not returned when her mother arrived to take her for lunch just before 1pm.
- NHS staff reported Catherine missing to Metropolitan Police at 1317hrs and after applying the Right Care Right Person Policy, they declined to investigate because Catherine’s registered home address had not been visited.
- At 1328hrs, Catherine’s father rang MPS to report her missing, providing additional information about an earlier suicide attempt and detailing that she would not return to her home address – the Met again declined to investigate.
- At 1402hrs, Catherine’s father rang the Met again to confirm her address had been checked and she was not at her flat.
- The Met then spent some time bouncing the incident log around various areas of London and the operations inspectors did not properly grip the incident.
- At 1539hrs Catherine father called the Met as there had been no response from the police and this was passed to the operations room.
- At 1602hrs inspector was informed of the phone call from Catherine’s father and read the CAD, at last putting in train enquiries to establish the level of risk (some of which was already known to the police).
- The log was eventually graded as high risk around 1700hrs and an investigation started.
- They received telecoms information 60-minutes later Catherine’s phone was in the Dover area of Kent and they informed HM Coastguard and eventually Kent Police. They found her on a cliff near Dover and Catherine died whilst negotiations took place to bring her to safety.
RIGHT CARE, RIGHT PERSON POLICY
It is the early call handling and the RCRP policy which became of interest to HM Coroner. In her matters of concern, the Coroner informed the police –
- First Matter of Concern –
- There was an overly rigid approach to the Right Care Right Person policy, resulting in a delayed deployment.
- Even where call handlers have real concerns someone has not returned to a mental health unit is a high risk missing person, the outcome of the RCRP toolkit is the same regardless of whether the individual’s address has been visited, even if given reliable information the person would not go there or had gone somewhere else.
- The way in which the policy is applied removed discretion from call handlers and despatchers to commence investigations whilst checks at the address were being conducted.
- Evidence was given at the inquest the call handler for the second call to the police attempted to convey her concerns to her supervisors that there should be an immediate deployment and was advised the police would not deploy.
- Second Matter of Concern
- A call handler informed SLAM to call London Ambulance Service to do a welfare check at the home address of the patient in circumstances where the ambulance service will only attend an address if the resident is known to be there
The jury found a number of things “possibly contributed” to Catherine’s death –
- The call handler and despatch team applied the Right Care Right Person policy and Affinity Protocol too rigidly, by not registering previous suicide intention resulting in a delayed deployment
- The Metropolitan Police categorising Catherine as a high risk in an untimely manner
- Internal communication didn’t utilise existing information held within all available CADs which resulted in delays to the investigation.
To my knowledge, this is the first time a jury has linked the rigid application of RCRP to an adverse outcome but it is not the first time rigid application has been called out, including notably at the Southport Inquiry a few months ago.
WIDER PICTURE
So there is nothing new here, sadly. In fact, there is plenty that should already be history because of other inquests which mention RCRP – when I keep hearing about lessons learned or scanning PFDs for learning, I’m way beyond believing it, frankly and mostly because what we’re are seeing here in Catherine’s case and the others, is exactly what we should have been expecting to see and exactly what some of us said would happen.
When I read repeated use of the words “overly rigid” in Catherine’s case, I was immediately reminded of the last PFD to be published which mentioned RCRP: the death of Lisa Taylor-Penny (Cheshire, 2025) where the Coroner used a memorable turn of phrase, “tramlines, not guidelines“, pushing in the same direction as “overly rigid”. There are several other “RCRP inquests” where the police asked the ambulance service to deploy to a situation where the patient’s location was not known, including the deaths of Sebastian Oliver (West Midlands, 2024) and more than half of the inquests I’ve traced so-far involve a wilful non-response by the police to situations where it seems arguable the so-called threshold for RCRP was satisfied.
So here are just a few of the themes which will have to feature in a thesis over the next few years. It does hark at lessons learned, because this topic has been raised before an generic police answers can be found after a lot of tricky inquests where they promise to learn lessons, adapt policy or change training or guidance, etc. The PFD for Catherine Morgan was accompanied by the response of the College of Policing which is a confused letter and seems to turn in on itself.
“TOOLKIT” REVISION
The College PFD response states –
“Revision of the Right Care Right Person toolkit guidance –
The College will revise the national Right Care Right Person toolkit to explicitly reinforce the requirement for professional judgement in all cases. This will include clear direction that risk to life and vulnerability must take precedence over process driven decision making, and that deployment should not be unduly delayed where a real and immediate risk to life or serious harm is identified.”
Read that again now you’ve read it – thanks. Now look at it: isn’t it rather amazing that some four years this thing began to roll-out unevaluated, we have “clear direction that risk to life and vulnerability must take precedence over process …” Why would this need reinforcing or clear direction? – wasn’t it the very essence of what Chief Constables reassured us about as RCRP grew and began to roll out. It’s certainly what two former Chief Constables said when they appeared as witnesses before the Health & Social Care Select Committee in September 2023 so how have we got almost three years beyond that and we now need to give “clear direction” about the central plank of this programme?!
This is literally life and death stuff as the inquests and PFDs continue to mount and to have to think there may been insufficient emphasis on this central tenet of the approach is depressing, to put things mildly. I have to remember as well the training material I was obliged to read as a serving officer did not have the correct definition of an immediate risk to life and I met no staff who had been told about the Melanie Rabone case from 2010, from where we draw the definition of an immediate risk to life.
STANDARD RESPONSES
The College of Policing’s response is the first one I have noted where there seems to be some acceptance that things aren’t entirely right. Whether that reflects learning by the College or recognition of some of the problems with the original support materials, it’s hard to say. However, I’m reminded of the proverbial iceberg when we see the deaths after police contact. There is undoubtedly a body of incidents which do not end fatally and so escape the scrutiny of HM Coroners. The reason I know this is because I had to contact a police force a few months back for reasons connected to this debate and they just flatly declined it in circumstances where I was just left utterly speechless.
This programme, unevaluated as it is, has done something profound to the culture and notwithstanding the legitimate problems it aims to address, it is having impacts which need looking at – so many of the near-misses will be non-fatal incidents more by luck than management and these are the stories you hear from paramedics, AMHPs and others if you listen to them long enough – we even heard this said on the record, under oath at the Nottingham Inquiry.
No doubt, this story is to be continued …
My latest figures now stand at –
- 28 completed, identified inquests
- 2 completed, unidentified inquests
- 23 Preventing Future Death reports from those 28
- 15 other deaths pending inquest or inquiry conclusion where I suspect RCRP will be a factor – and of course, I might be wrong but I’m monitoring them until I know.
Awarded the President’s Medal, by
the Royal College of Psychiatrists.
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All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2026
I am not a police officer.
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