Source · Prevention of Future Deaths
Mark Harris
Ref: 2019-0023
Date: 17 Jan 2019
Coroner: Jacqueline Devonish
Area: Suffolk
Responses identified: 0 / 2
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Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
Date
17 Jan 2019
56-day deadline
18 Mar 2019
Responses identified
0 of 2
Coroner's concerns
Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
View full coroner's concerns
(1) The 999 call was directed to the ambulance service for a welfare check The suicide protocol was initiated by the call handler took key information: When the police were called the mis-spelt name of the deceased as HAIS was provided to them together with detail of the nature of the welfare call as 'messaging all night threatening to kill himself' The police attended the address Had the correct spelling of the name been provided to the police they would have known Mark Harris and his history of suicide attempts_ This was a significant problem for an intelligence led service_ (2) It was unclear to the police that they were asked to attend to safeguard ambulance personnel not to undertake a welfare check: The protocol used by the call handler did not make provision for that to be stated.
(3) The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD_ (4) There is no agreed protocol between the ambulance and police services facilitating communication to formulate an ambulance service protocol which incorporates information helpful to the police_
(3) The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD_ (4) There is no agreed protocol between the ambulance and police services facilitating communication to formulate an ambulance service protocol which incorporates information helpful to the police_
Report sections
Investigation and inquest
On 7 January 2019 commenced an investigation into the death of Mark Harris, aged 24, The investigation concluded at the end of the inquest on 16 January 2019. The conclusion of the inquest was that the death was a misadventure with a medical cause of death of asphyxia due to hanging contributed to by his mental health, the communication of bad news by his AFCASS Officer that morning, the volatile relationship with his ex and the communication failure between the ambulance service and police, and between the police control room and attending officers.
Circumstances of the death
On 11 January 2016 Mark Harris was found deceased with a rope around his neck at the home of his ex-partner where he was residing at the time Mr Harris had been taken into police custody between 8 & 10 January 2016 for amongst other things common assault against his ex-partner and breach of bail conditions to attend her property. Upon his release he went home to his ex-partners address where he was living alone, with her agreement: He messaged his ex that evening and threatened to kill himself if he could not be with her He had a history of self-harm and was well known to the police. When nothing was heard from him the following day his ex called 999 for a welfare check at about 1.40pm The ambulance service requested the attendance of police when the ex-partner indicated that he could be violent The ambulance service graded the call for attendance within 30 minutes_ The police initially attended around 2.3Opm leaving at 3.1Opm, and then again after Spm: They requested additional information from the ambulance service and their own control room to identify the occupant of the property: were unaware that the ex-partner had said he was definitely in the property and unaware that she had a and was only 30 minutes away_ Neither were they made aware of the recent custody or the conditions of bail when they told the control room that they suspected it was Mark Harris and not Hais The ambulance service first attended at 4.38pm due to the heavy demands on the service that day, but there was a further delay in gaining access to the property until the ex-partner attended with the around 5.1Opm: Mr Harris was found to have ligatured. The ambulance service recognised life as extinct immediately: The believed that they had been asked to conduct a welfare check on a Mr Hais They key key police
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action:
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Report details
- Reference
- 2019-0023
- Date of report
- 17 January 2019
- Coroner
- Jacqueline Devonish
- Coroner area
- Suffolk
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Mar 2019.
Sent to
- Emergency Operation Centre Norwich
- Melbourne Ambulance Station