Source · Prevention of Future Deaths

Jaroslaw Rogala

Ref: 2016-0145 Date: 14 Dec 2016 Coroner: Dr Fiona Wilcox Area: London Inner (West) Responses identified: 1 / 2 View PDF

Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and supervision during crises.

Date 14 Dec 2016
56-day deadline 9 Apr 2017 est.
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and supervision during crises.
View full coroner's concerns
That those patients with addiction are risk of suicide as there are no in-patient facilities to admit them for care and supervision when in crisis in circumstances as described in this case. 7

Responses

1 respondent
Greater Manchester Police Police / Law Enforcement
PDF
Action Planned

• Greater Manchester Police (GMP) is investing in technology to replace existing systems with one user experience to improve information management and sharing. • Mobile technology is being distributed to operational staff to provide direct access to GMP IT systems for improved information access and decision-making. • GMP is undertaking a procurement, design, and testing process before implementation, scheduled for late 2017. (AI summary)

View full response
Dear Ms Kearsley Re: Adele Bernadette Blakemen (deceased) Thank you for your report sent by letter dated 15th April in respect of Adele Bernadette Blakeman deceased pursuant to_Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and paragraph 7 , Schedule 5 of the Coroner's and Justice Act 2009. reply to your concern as follows; Extract_trom_Regulation _28 report_point 1 The GMP computer system hinders officers and does not afford them easy access to important information within the timescales they have available to them, in order for them to adequately assess situation: Concerns around the efficiency of GMP's antiquated computer system have been raised now On a number of occassions and have featured in several inquests GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS): The programme will also improve integration of components outside of these core systems, replace ageing data warehouse capabilities and moving to data centre managed externally by a reliable supplier: Also as part of this programme of work, mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making: This mobile_technology will enable frontline officers responding to calls to have direct access to GMP IT systems and the important information contain_ Given the complexity of this change programme, GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017_ Extract_from Regulation 28_repott_point 2 There is a failure to record pertinent information about an individual on the intelligence section of an individual nominal profile. There were 5 PPI logs available to officers, no crucial pertinent information from these logs had been placed in her intelligence section, officers would have had to access each of these logs individually and read through the entire entries to elicit any inforamtion which may have been relevant For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There. was also on one mention of involving BTP should there concerns about this individual, this partnership working was lost in the midst of one PPI log: Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street; Openshaw; Manchester M1 2NS being they

Cont.d pg 2 In respect of PPI logs, it is the responsibility of the officer submitting the PPI to submit any relevant intelligence from within the report. By the end of August all supervisors from within the Public Protection Investigation Units and who are responsible for the finalisation of any vulnerable adult PPI s will be reminded that on finalisation must quality assure the PPI with ensuring that intelligence is submitted were appropriate. This will also give them the opportunity to review any warnings, in the case of Adele both a suicidal and self harm warning would have signposted the user to fact that within that record there is information pertaining to the reason for the warning: GMP do still receive information from British Transport Police. come in two formats, one of which is managed through the Force Intelligence Bureau and the other via Divisions_ From here on in the FIB will ensure that a record of the existence of both is inputted onto the nominal action board with any trigger plans_ is taking this forward and will look at ways to improve any information sharing agreement: Extract from Regulation 28_report point 3 There was & failure to esculate this call as per the escalation procedure to & divisional Inspector for a review: It is accepted that this case was not escalated to a divisional inspector as it should have been In March 2016 Chief Inspector 05718 from the Operational Communications Branch (OCB) revised the FWIN Escalation Policy the revised version is currently at the end of the consultation phase. The new FWIN Escalation Policy sets out process for both OCB staff and divisional supervisors to make informed decisions about the escalation of incidents the National Decision Model (NDM) In principle, it aims to ensure resources are deployed to deal with any incident in a timely manner based purely upon threat; risk and harm, and not based upon the existing time based escalation points as per the existing policy document: It is anticipated that the new policy will be in place by August 2016. Extract _from Regulation 28,_report_point_4 There is a lack of understanding of the role of the IMU in missing person enquiries In January 2014, appreciating the threat,_risk and harm that is constantly being managed within the OCB Chief Superintendant 15086 implemented Risk Support Team (RST) The RST is an interim measure to support the overall function of the OCB in managing threat;, harm and risk alongside the wider organisational learning that has been identified from Regulation 28 notices, IPCC recommendations and critical incidents_ The role of the RST is to support command and control by 'identifying risk and vulnerability to victims, offenders and police officers as well as other members of the public. The RST conduct background intelligence checks that are far more detailed and complex than those carried out by divisional radio operators some systems that only the RST have access to This is predominantly done by trawiing the iS queues, scrutinising all incidents regardless of grade and summary heading: Postal address: Greater Manchester Pollce, Openshaw Complex; Lawton Street, Openshaw; Manchester M11 2NS they along the They along using using

Cont.d pg 3 The RST also deal with: FWINS that have been switched, where a radio operator feels there is a requirement for enhanced checks, where there is already a greater concern of risk Incidents that require time consuming telephone enquiries Liaison with partners , especially when checks reveal that are the most suitable agency to deal: Assisting with critical incidents and some high risk MFH enquiries. Protracted enquiries to try and locate victim when we have not managed to establish contact Searching FWINs closed on G16 (vulnerability) and update the KH details with pertinent information. Merger of duplicate OPUS records Staffing on the RST consists of one supervisor and 5 teams of 2 staff; all of whom foliow the command and control shift pattern, covering from 0700 to 0200/0300. In light of this regulation 28, the role of the Information Management Unit has been highlighted throughtout the OCB via inclusion on Divisional Orders on 27th 2016 , This highlights their role in the triage of MFH incidents amongst their other duties_ Aditionally in May 2016, Professional Standards Branch chaired organisational learning meeting with OCB, Public Protection Division and the Force Missing From Home Manager: It is proposed that we will be able to report back to the Coroners in July 2016 in terms of the wider work completed around vulnerability, including the lessons learnt from this case.

Report sections

Investigation and inquest
On 8th November 2016, and 25th November 2016, I heard the inquest touching the death of Jaroslaw Rogala (otherwise known as Jarek). Medical Cause of Death 1 (a) Hanging How, when and where and in what circumstances the deceased came by her death: Jarek was dependent on alcohol. When intoxicated he suffered with suicidal ideation. On 3/9/2016 he was found hanging in his bedroom deceased. There were no suspicious circumstances. He was heavily intoxicated at the time of his death. Conclusion as to the death He took his own life whilst intoxicated with alcohol
Circumstances of the death
In the days leading up to his death he had attended St. George's Hospital on the 30th and 31st August consecutively with suicidal ideation in association with social stress and. alcohol misuse. On each occasion he was seen by Liaison Psychiatry and discharged to GP follow up. Admission had been requested but he was told that there was nowhere that he could be admitted to. He was not sectionable under the Mental Health Act. In evidence the court heard that there is no facility to admit patients in whom the primary diagnosis is dependence on drugs or alcohol under the psychiatric services in such circumstances. Further admission under the medical teams for detoxification requires a medical indication. As such there is no ability to admit such a patient into a "safe" space when in crisis for care and supervision. Essentially patients with dependence are thus discriminated against by psychiatric services, with addiction being regarded as a personal choice on the part of the patient rather than being treated as an illness.
Action should be taken
YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 14th December 2016 Dr Fiona J Wilcox HM Senior Coroner Inner West London Westminster Coroner's Court 65, Horseferry Road London SW1P 2ED

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Report details

Reference
2016-0145
Date of report
14 December 2016
Coroner
Dr Fiona Wilcox
Coroner area
London Inner (West)

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Apr 2017 (estimated).

Sent to

South West and St George’s Mental Health Trust
West London Care Commissioning Group

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