Whilst my PhD is focussing on Preventing Future Death reports (PFDs) illuminating issues around Right Care, Right Person (RCRP), I still maintain my spreadsheet about mental health police contact deaths more generally. It’s an important, broader context for RCRP and it currently sits at 355 MH-PCDs, giving rise to 193 PFDs where 45 are still pending an inquest or inquiry outcome. My regular delve in to the published PFDs on the Chief Coroner’s website more often see me updating the larger spreadsheet, than the former.
Last week, I was caused to think about RCRP when cataloguing a PFD notice which was definitely unconnected to it, because it related to the police in Kent agreeing to conduct a welfare check on someone, well after RCRP had commenced in their area. A man known only as “PM” in the Coroner’s notice had been arrested and bailed for potential offences of possessing indecent images of children and the PFD notice rightly points out, this is a high-risk matter when it comes to releasing suspects.
Bail can often be required because thorough investigation often requires digital analysis of electronic devices and that can take many months – and there can be other reasons. A period where someone is on bail for potentially life-altering, humiliating offences can put people in a very difficult and dark place, even if innocent of the allegations. “PM” had been assessed in custody by the Liaison & Diversion service and no additional risks were identified, beyond whatever risk you think is “normal” for someone arrested for such offences.
WELFARE CHECK
After he was bailed in June 2025, his family became concerned about his welfare and a friend visited him that evening. Unable to raise a response, they contacted the police and a welfare check was completed. The officer who attended PM’s home established contact with him and there being no immediate action required, left him at home on bail.
The Coroner, it should be noted and for the avoidance of any and all doubt, had no concerns about the diligence or seriousness with which the officer approached the task, describing her as “kind and compassionate” and doing “her best to conduct the welfare check”, albeit noting a lack of training.
PM was found deceased at his home address around 24hrs later.
I have no issues at all with the police deciding to check on him – none at all. This is despite their being no legal obligation on the police to conduct any additional checks for someone who is on bail for an offence, than they would for anyone else. His family raised concerns after being unable to raise him and “somebody” should “do something”. I have experience of raising concerns about someone arrested for not-dissimilar offences and being dismissed on the basis of RCRP.
HOW TO DECIDE
My query here is on what basis they decided to do so and this is where, yet again, PFDs let us down by not telling the whole story.
So how was the RCRP threshold applied to this one?
Welfare check requests under RCRP are about the application of a published threshold on the need for a check. Is there a crime (no) or is there an immediate risk to life or an immediate risk of serious harm / degrading treatment? Well, the PFD ultimately does not make this clear – so we have to accept “there could have been” whilst nothing makes it look likely.
The extent to which the police were affected in their judgement on this by them having arrested the man for a suspected offence, albeit one where there was formal risk assessment by police and by Liaison & Diversion of not raised concerns, means I’d be interested to know more but I repeat: the fact someone is on bail for an offence raising no additional obligation than would otherwise exist.
UNDERSTANDING & LEARNING
An incidental point given the incompleteness of the PFD or any other public record: I’m increasingly coming to the view Coroners in the UK should publish a full report after an inquest, much as the UK courts produce a written judgment in criminal or civil proceedings. This reflects practice in Australian coroners’ courts and by way of an example, a 34-page report after the death of Courtney Topic in Sydney, New South Wales (2017) shows us what is possible and allows us to know what went on. This increases potential for learning because by the end of this post about PM, even if you have fully read the PFD notice, you will probably still have outstanding and unanswerable questions about what exactly went on or why, and what needs fixing.
I certainly have.
So I’m raising here the question of consistency, notwithstanding all cases turn on their individual merits and it’s rare someone would be in possession of all known facts. On what basis are we agreeing to checks like this, given the RCRP threshold does not appear met, yet the force concerned have agreed to do it.
What are the rules here? – indeed, what game are we actually playing?!
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, 2026
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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