Joyce Carney

During the course %f the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In circumstances it is my statutory to report to you; During the Inquest evidence was heard that:- When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient; The risk assessment did not involve, nor include, the Police Officers who were observing patient: The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in Hospital, visitors to the Hospital; members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient_at the Hospital,_focussed on the Patient and the fact that Injury the the duty the the Patient may seek to leave the Hospital but the assessment did not include any discussions or Iiaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital. iii_ There was no Iiaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital The lack of Iiaison led to Police Officers believing that a escape existed at the end of Lowton Ward and to side of the Patient's bed, which had to be protected to prevent the Patient the Hospital. The Officers believed that the fire escape involved a 20 to 30 foot drop from the 2nd floor of the Hospital onto an open area outside the Hospital building, which could be used to leave the Hospital or to commit self-harm: In fact the evidence at the Inquest established that the fire escape was not a fire escape but simply a fire exit into a corridor leading into another Ward within the Hospital without any exit door or exit from the building: Focus upon the fire exit and a belief that there was an exit in the corridor led to the Police Officers making a decision to sit on one side of the Patent's bed, and at the foot of the bed, leaving the side of the bed facing exit to the Ward open for the patient to leave the Hospital: Furthermore the Officers at the Hospital raised concerns with their Supervising Officer, namely a Sergeant at the Police Station, in relation to the Patient being agitated and threatening to leave the Hospital during the afternoon of the 21st December 2014 but neither the Sargent nor any other senior Officer attended the Hospital to conduct any further risk assessment or to reassess the situation.
iv. There are no agreed protocols, policies or procedures between the Greater Manchester Police and the Royal Albert Edward Infirmary, Wigan in relation to joint risk assessments for patients detained at the Hospital under arrest or in the presence Of or supervised by Police Officers_ Furthermore there is no protocol, in relation to Iiaison and consultation between the Greater Manchester Police and Hospital to formulate risk assessments in relation to patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers. During course of the evidence it was accepted that risk assessments conducted by either the Police or the Hospital, and any joint risk assessments, should focus upon the Patient but the assessments should also include the protection of other patients in Hospital, visitors to the Hospital, members of the public and staff employed in _the Hospital fire the leaving the the the the

The evidence at the Inquest indicated that the absence of protocols; policies and procedures in relation to joint risk assessments as between the Police and Hospitals is likely to arise in relation to the detention of patients in many Hospitals in United Kingdom where patients are detained under arrest Or in the presence of or supervised by Police Officers:
vi. The evidence at the Inquest accepted that; if the Patient had not been able to attempt to leave the Ward in the Hospital, the Deceased would not have suffered the injury , which contributed, to the cause of her death. vii At the Inquest it was accepted by the Police and the Hospital that patients are taken to Royal Albert Edward Infirmary, Wigan on weekly basis under arrest or in the presence of or supervised by Police Officers and on many occasions a patient; in the presence of the Police, is admitted to Ward in the Hospital from the Emergency Department. Accordingly, a risk assessment in relation to the location of patient in the presence of the Police, either in the Emergency Department or in Ward, is an important factor in risk assessments to protect other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital, particularly if the patient is known to be violent or the patient has a previous history of sexual offences. Such matters may only be within the knowledge of the Police and Iiaison between the Hospital and the Police is critical to enable such information to be considered within the risk assessment and to enable the Police to be aware of the layout of the Hospital:
viii. The evidence raised concerns that there is a risk that future deaths will occur in similar circumstances to the Deceased, and in other circumstances, unless action is taken to review the above issues.
2. I request the Greater Manchester Police and the Wrightington Wigan and Leigh NHS Foundation Trust to consider the above concerns in relation to Hospitals under the management of the Wrightington Wigan ad Leigh NHS Foundation Trust and I request the Greater Manchester Police to further consider concerns in relation to all Hospitals in the Greater Manchester area I also request the Home Secretary and the Secretary of State for Health to consider the above concerns in relation to all Hospitals in the United Kingdom: Irequest the Home Secretary, the Secretary of State for Health; the Greater Manchester Police and the Wrightington Wigan and Leigh NHS Foundation Trust to carry out reviews with regard to the following:- The security of patients under arrest or in the presence of or supervised by Police Officers in any location within a Hospital: the the the

The protection of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital whenever patient is detained under arrest or in the presence of or supervised by Police Officers in any location within Hospital, iii The provision of protocols, policies and procedures as between Police Forces and Hospital Trusts in relation to the formulation of joint risk assessments and the inclusion of liaison and consultation between Police Forces and Hospital Authorities in the formulation of joint risk assessments in relation to patients detained at Hospital under arrest Or in the presence of Or supervised by Police Officers: The purpose of the protocols, policies and procedures would be to protect the individual patient detained by the Police and to consider and protect other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital; The Home Secretary and the Secretary of State for Health would be in a position to bring the concerns to the notice of all Police Forces and Hospitals in the United Kingdom to enable concerns to be considered in individual areas or regions as between individual Police Forces and individual Hospital Trusts on a nationwide basis. It is accepted that some Police Forces and Hospital Trusts may already have appropriate protocols, policies and procedures in place but the evidence at the Inquest was that did not exist in many Hospitals in the United Kingdom. The need for a review both in Greater Manchester and on a nationwide basis when a patient is detained at a Hospital under arrest or in the presence of or supervised by Police Officers relates to the fact that there are special considerations in relation to risk assessments in relation to such patients that do not arise in relation to patients who are not detained under arrest or in the presence of or supervised by Police Officers: ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action; YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by Znd June 2016. 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 actionOtherwise You must explain whyno action the they is proposed: COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Carney's daughter _ Iam 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; coroner_ at the time of your response, about the release or the publication of your response by the Chief Coroner_ Dated Signed Q 7th April 2016 Alan P Walsh HM Area Coroner the