Paul Hanton

Coroner's concerns

AI summary

Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.

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1) Need for clear information to be given by hospital staff when making the 999 call to report a patient has gone AWOL in order to proactively answer the known risk questions and maximise the opportunity for police to take timely action to trace the patient within the golden hour_ heard (Service Director, that when a 999 call is made relevant information would need to be drawn from several sources including the patient's form (personallphysical details & photo), any signing inlout form (last known clothing) and latest risk assessmentslplan with details of recent incidents that inform the risk assessment Inevitably, when a patient goes missing the AWOL policy needs to be followed including internal and external searches; notification of relevant senior staff etc. At times of pressure such as these it would be advisable to have all the relevant information in one location for ease of access by the designated person who makes the call:
2) Langley Green to ensure that hospital CCTV is accessible at all times for police viewing:
3) Langley Green to consider review and amendment of current AWOL policy. This may be necessary given indication that he does not believe staff need to wait to have a discussion with clinical staff.
4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces
5) Police to consider joint policy with Adult Safeguarding Board.
6) Police to consider equal response to informal as well as sectioned patients if guided by clinical staff of high risk heard from senior staff at Langley Green that there is a discernibly different response from police when the missing person is an informal patient rather than under a MHA order. In the latter case, often a blue light police car is immediately dispatched to the hospital and a room/locality search takes place_ This is not the case with an informal patient yet the same high risk of self-harm or suicide or risk of causing injuries to others may exist: In other words, there seems to be a general perception that informal patients are less unwell:

Responses

2 respondents

Sussex Police Police / Law Enforcement

13 Mar 2018 PDF

Action Taken

The police force updated its missing person policy in September 2017, including new call handling guidance with mandatory risk level recording, and delivered related training to staff between January and March 2017. They also have a joint policy with Sussex Partnership NHS Foundation Trust regarding absent patients, which is currently under review with planned consultation with Safeguarding Boards. (AI summary)

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Dear Ms Schofield, Re: Inquest into_the death of Paul HANTON_ Zth December 201Z write in response to your formal report under Regulation 28: Report to Prevent Future Deaths_ Missing Person reports are always taken seriously by Sussex Police and our thoughts with the family and friends of Paul Hanton. We are always to review and improve our practices, and how we work with partner agencies, to ensure better safety for all members of the Within the report you highlight that during the course of the inquest the evidence revealed six matters of concern, and you felt that future deaths may occur unless action is taken to address them: Points one; two and three (as numbered in the report) will be responded to by Sussex Partnership NHS Foundation Trust directly to you: With regard to point four, new call handling guidance within the force missing person policy was published in September 201- and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled 'Missing person policy, Appendix B: call handling guidance' This followed a review of Sussex Police's response to Missing Persons. The detailed design process subject of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the of call, This included scenario based exercises and was delivered over a 12 week training cycle between January and March 2017 prior to the new process being invoked in May. It was further audited in June before the policy went in September 2017 . All inspectors who perform the role of the Duty Inspector were also required to attend a Continued Professional Development two day course between March and 2017 around the management of threat; harm and risk and the need to document decisions clearly within CADs. The guidance also outlines the level of response to Missing Persons following the decision to grade them as either high risk, medium risk, low risk or absent: Referrals to other forces however are not dependent on the risk grading but on the information and necessity to do so in order to locate the individual and ensure their safe return. The supervisor overseeing the initial report would consider the need t0 inform other forces including British Transport Police as soon as possible if there was the suspicion the missing person intended to travel outside of the county, whilst the handover process in place for managing Missing Person reports includes regular reviews and scrutiny which would identify the need to make such contact if it had not taken place. Police Headquarters Malling House Church Lane Lewes East Sussex BNZ 2DZ Telephone 101 Fax (01273) 404263 Website: http:/lwww sussex police.uk e-mail: chiel constable@sussex pnn police.uk are willing public point live May

Point five identifies the need to consider a joint policy with the Adult Safeguarding Board. Sussex Police and Sussex Partnership NHS Foundation have a jointly agreed policy relating to patients absent without leave / informal missing patients which applies to all patients including those detained under the Mental Health Act 1983, subject to Guardianship, Supervised Community Treatment Orders as well as those in hospital informally: The document provides guidance for managers and staff regarding duties, responsibilities and actions to be taken when a patient is absent without leave and provides the legal framework which sets out these duties and responsibilities_ This Policy (a copy of which is attached) was due for review in November 2017 and is currently in the process of consultation with all partner agencies prior to the finalisation of any amendments and additions. It will also consider and include any recommendations from HM Coroner: As part of the review an approach to the Safeguarding Boards will be made to invite their comment on the policy, and if appropriate to include them as a partner agency in the Policy. In working closely with the Chief Executive of the Partnership Trust; have also suggested introducing a mechanism that will allow us to monitor the use and effectiveness of this policy. Point six asks the police to consider whether there is an equal response to informal as well as sectioned patients if they are assessed by clinical staff as high risk. can assure you that whether they were an informal or sectioned patient would be noted but would not determine the level of response_ This is determined by the level of risk which is a combination of the likelihood of harm coming to the missing person or the wider public, and the potential seriousness of harm that might result: am satisfied that we now have the relevant processes and policies in place, and that all decision makers have been appropriately trained.

Sussex Partnership NHS Trust NHS / Health Body

16 Mar 2018 PDF

Action Taken

The Trust created a checklist of information needed by police during 999 calls about AWOL patients, which is being incorporated into the Trust's AWOL policy. Instructions for accessing CCTV have been positioned next to the computer, and staff have been trained on using the system. (AI summary)

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Dear Ms Harrold Re: Inquest into the death of Paul Lawrence HANTON _ 5 to 7 December 2017 Thank you for your letter dated 22 January 2018 enclosing your Report to Prevent Future Deaths under Regulation 28 Coroners (Investigations) Regulations 2013. write to formally respond and to provide you with details of the actions taken by the Trust as result of matters revealed during the Inquest: will address each of the three Matters of Concern, identified within your Report, in turn: Need for clear information during 999 call During the course of the Inquest; the Trust recognised that it would assist with the making of the 999 call if the specific information required by the police was fully collated beforehand_ Thus, the Checklist document; which Jo Scott provided to you at the Conclusion of the Inquest;, was created. That Checklist is based upon the specific questions that the police ask during a 999 call as well as the additional information that the Inquest evidence identified as being of assistance_ In your Report you identify that having all the relevant information in one location would be advisable to assist the 999 call-maker: Moreover, you identify the need for the information to be provided to the police within the 'golden hour'_ wholly agree that clear , effective and timely communication between the Trust's staff and the police is essential when a patient has gone AWOL and, to ensure that Trust staff provide such communication, confirm that the Checklist is now being incorporated into the Trust's new AWOL policy: Whilst this is yet to be finalised, enclose a copy of the version of the Checklist that will appear in the new policy at Appendix D Additionally, enclose copy of the new AWOL policy's Appendix C Flowchart which directs staff to the Appendix D Checklist: CCTV accessibility confirm that the CCTV used at Langley Green is now accessible at all times for police viewing: enclose copy of the staff instructions on how to access that CCTV. These Interim Chair: Richard Bayley Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP WWW sussexpartnership nhs_Uk teaching trust of Brighton and Sussex Medical School Trust;

instructions are positioned next to the computer that controls the CCTV so that any member of staff can access the system for the police. Additionally, confirm that; as needed, staff have been provided with training to ensure that are confident in accessing the CCTV system. Whilst your Report is limited to Langley Green, would like to assure you that we will ensure that the police have access to all the CCTV that we are in the process of installing this year: Review of AWOL policy In your Report you recommend that we review our current AWOL policy and consider amendment of it in the light of evidence As understand it, during his evidence he questioned the need to await input from the Responsible Clinician (RC') to the 999 call being made, contrary to stage 3 of the current AWOL_policy's Appendix C Flowchart. As you will have already appreciated from the above, the Trusts AWOL Policy has now been reviewed and the Appendix C Flowchart revised to accommodate the new Appendix D Checklist: However , as you will see, the decision has been taken not to alter stage 3 of the Appendix C Flowchart. Thus, inclusion of the RC in the risk discussion remains_ The rationale for this is that we are confident that staff are able to respond to the level of urgency required in an AWOL situation, understand that the Flowchart is guidance and that it is not an absolute requirement that speak with the RC As in Mr Hanton's case, we are confident that staff would respond to the urgency of the situation and make the 999 call without delay, if the RC wasn't immediately available_ trust that the content of this response and enclosures address your concerns and provides you with complete reassurance. However if any further clarification is required or can assist further in any way then please do not hesitate to contact me_

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Investigation and inquest

On 12th May 2016, the Senior Coroner, Penelope Schofield, commenced an investigation into the death of Paul Lawrence Hanton 52 years old. investigation concluded at the end of Ihe inquest on December 2017 . recorded a conclusion of Suicide: medical cause of death was recorded as: 1a) Head injuries_

Circumstances of the death

In summary, Paul Hanton was an informal patient at Langley Green Mental Health Hospital in Crawley since January 2016. On Monday 18h April 2016,he was escorted around the grounds of the hospital with two olher patients by a member of slaff. As they were returning to the ward, Mr Hanton absconded and despite a search within minutes of him leaving he could not be found either in the hospital or the near vicinity. His disappearance was immediately reported (o Sussex Police. 8 days later on 26th April 2016.at 23.57_hrs_Mr Hanton jumged in front of a train as it entered Cross aged The 7th The Kings

Underground Station: A post mortem examination was carried oul on 6th May 2016 and confirmed he died from head injuries_ It was clear Mr Hanton had a complicated medical history including both physical and mental health problems over many years_ In particular; he had suffered from depression since his teenage years and it was reported he had suffered from PTSD as a result of abuse. At one time there was a diagnosis of borderline personality disorder and following his admission to Langley Green, his psychiatrist, Itold me his working diagnosis was depression wilh psychotic symptoms_ Mr Hanton's first admission to Langley Green hospital was on 26 May 2015 following two attempts to take his own life firstly on 14 when he took an overdose of tramadol and venlafaxine then on 24 when he again took an overdose of the same drugs and by cutting his brachial and his wrist with a knife requlring surgery. Various attempts were made to try home leave and rehabilitation back into the community but these did not go well resulting in a Mental Health Act assessement in August 2015. Mr Hanton was deemed to have capacity but was readmitted informally due to poor self-care and persistent false concerns about money and debt: Treatment continued and by 23 November a discharge meeting was planned but that morning Mr Hanton told staff he was going for a walk and he did not return: He was not found until 16 December by his father in Hastings, East Sussex intention was to go to Langley Green the following day to collect his belongings but he again went missing from home on 17th December. He was next admitted to St Thomas' hospital in London on 31 Dec after taking a large overdose of aspirin tablets in an attempt to lake his own life_ He was admitted with a perforated ulcer and underwent surgery: Following treatment he was readmitted to Langley Green on 13 January 2016 again as a voluntary patient: By 22 February 2016, Mr Hanton was not keen on having an assessment at a rehabilitative unit prior ta discharge home and tried to run away but was easily stopped by staff. He again talked about taking his own life accepted that he 'freaked' out and became fixated on himself, His up and down mental health continued until 16 March when he went on unaccompanied leave and failed to return: On impulse, he went to Southampton where he swam out to sea with the intention of ending his life but later swam back to shore and was found by a passer-by who called the police and was returned to hospital: He told the doctor that he heard voices telling him to kill himself , Staff assessed his risk of self-harm as high s0 he was placed on 15 minute observations and encouraged only to have accompanied On 14 April he reportedly started a fire in his room during the night and suffered burns as a result The 15 minute observations were resumed and discussions began to change medication to include a mood stabiliser, Lithium, and also potentially electroconvulsive therapy. Mr Hanton was not keen on this course of treatment but again he was deemed to have capacity_ The last Mr Hanton was seen by staff was 18lh April. An activity worker knew that he enjoyed the walk around the hospital grounds s0 she went lo his room to encourage him to attend: Two other sectioned patients also joined them and the walk Itself was` uneventful until all returned to the hospital cafe. Enroute back to the ward, were joined by 2 relatives and passed through reception which was very busy that day: By the time the group reached the ward it was clear that Mr Hanton had gone without warning: Within minutes, the activity worker ran back to reception and checked with staff if they had seen him. Together with a colleague, they quickly ran out of the hospital grounds and searched the nearby area which she knew well. Despite a search of the hospital and grounds, he could not be found. During the inquest she told me that she could not recall exactly who made the call to the police_to report Mr Hanton missing_She was aware a second call was made bY the May May artery The and killing leave. day Ihey Ihey occupational therapist to provide additional details. After hearing from two charge nurses it was apparent that neither regarded themselves as being the Nurse in Charge. also heard from the Clinical Nurse Lead Manager_ who carried out a review of what happened on 18th April he too initially did not know who made the initial missing person call to the police_ Some notes were found and confirmed it was a staff member with initials When the audio file of the 999 call was played, it confirmed a healthcare assistant had been asked to make the call when he was not fully equipped with all the necessary information readily to hand. I heard from of the Sussex Police Missing Person Team_ He explained that the call handler on a 999 call uses a recognised Iist of questions to obtain the right information but it helps immensely if hospital staff can give the best information to inform the first risk assessment by the Critical Incident Inspector including, for example, description of clothing: This then helps trying to trace the person within the first hour when there is the best chance of finding them as if on foot are likely to no more than 3-4 miles away: Within the first hour local CCTV should be alerted and there can be area searches of buslrailway stations; trying mobile phone contact and familylfriends_ In this case the call started at 11.33 and ended at 11.47 so 14 minutes By 11.59 the Inspector was asking for more information buth confirmed that he could not see that the Inspector recorded the risk assessment despite the information given by the hospital and CCTV monitoring did not start till 13.37, two hours after the call. The second call from the hospital was at 12.00 and gave clothing description and absconding details from 16 March including the fact Mr Hanton had gone to Southampton and left a suicide note. NICHE and COMPACT records were checked The CAD record suggested that the incident was bouncing between the North and South Area inspectors with Iittle effective action taken. A local car commented on use of the rail network previously and being found in Hastings so a request was made to alert BTP which happened at 14.34. By 14.48 a local sergeant reviewed the compact report and indicated a medium risk despite the hospital having indicated a high risk of suicide_ It was not until 16.51 that the North Area Inspector requested a room search and that did not occur until 20.37 . This was when a broken plate with blood was found indicative of further self harm It was noted hospital CCTV could not be accessed and this may have helped in some cases A decision was made to leave the enquiries to the missing person team in the morning but at 21.26 a request was made for checks in a Hastings hotel and home address in Surrey: A home search was also requested of Surrey police and when this was done on 19 April at 02.30 there was a negative result: A further check happened at 09:17 again with a negative result: It was accepted that no foot patrol or drive arounds were conducted. Hampshire police were not notified until 19 April at 09.19_ next significant event was at 00:19 on 25 April when the Met police received a call from Baying Paul had rung his parents_ set out the actions by the Met including advising the parents to obtain the telephone number and a possible location. Officers were dispatched to check phone boxes in the Haymarket /Coventry St area and also around Tottenham Hotspur Football ground even though that was 10 miles away from where the call was believed to have been made. It was hoped that Mr Hanton was on his way home_ from BTP confirmed that at 23.50 on Tuesday 26th April a witness was on the platform at Kings Cross underground station when he saw Mr Hanton deliberately run across the platform and jump in front of a train as it was entering the station. Police found a notebook at the scene and from reading what Mr Hanton wrote there is no doubt and they get long; being The he had a clear intent to take his own life_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

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