Source · Prevention of Future Deaths

Anne Wilson

Ref: 2015-0293 Date: 21 Jul 2015 Coroner: Sonia Hayes Area: London (South) Responses identified: 1 / 2 View PDF

Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.

Date 21 Jul 2015

56-day deadline 15 Sep 2015 est.

Responses identified 1 of 2

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ (1) In 2014 the Metropolitan Police Service (MPS) introduced new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time: (2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain: (a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised (b) an example of how to manage a request for a welfare check concerning the mental health of an individual (c) how to manage additional information received once welfare check request had been closed: (d) The importance of updating those involved in the change in actions taken by the MPS
3) The information provided by Miss Wilson's G.P to the MPS was available in full with those making the decision to downgrade the request for a welfare check: Miss Wilson had suffered a relapse of severe depression had just been discharged from psychiatric hospital the welfare concern was raised by the discharging Consultant Psychiatrist and G.P (d) the G.P had specifically requested forced entry to Miss Wilson's property The MPS call handler informed Miss Wilson's G.P that the police would attend Miss Wilson's flat within the hour however the request for a welfare check was downgraded without _informing_the G P of the_change in_decision_ orto_seek South London Area Coroner' $ Office, ST. Blaise Building, Bromley Civic Centre, Stockwell Close; Bromley, Kent BRI 3UH being further clarification of his concerns.

(5) The MPS didnot share the G.P's mobile telephone number with the

Responses

1 respondent

London Ambulance Service NHS Trust NHS / Health Body

15 Sep 2015 PDF

Action Planned

A Control Services Bulletin will be issued by the end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient closed prior to assessment. Joint meeting governance arrangements are to be reviewed to ensure they are robust. (AI summary)

View full response

Dear Ms Hayes Thank you for your Regulation 28 Report to prevent future deaths, dated 21st July 2015, bringing to my attention the mattera of concern: what version of the MPS Welfare Check policy Is currantly in force and & final
6) It is unclear version has not been shared with the LAS despite requests to do s0 The MPS and LAS have joint working arrangements but have to meet t0 discuss joint
7) working arrangements under the LAS Welfare checks policy: careful consideration to the concerns raised and in this_ have been advised We have Director Of Operations and Diraclor of Nursing and Quality, &8 well as senior by the Trust's Control Services about the actions to ensure that the learning managers in the Emergency from this tragic incident is embedded: Metropolitan Police 'External Briefing Note welfare checks dated March 2014 A copy of the been provided following the inquest: No fundamental updated March 2015 V1' has December 2014 changes were ideritified with the previous Version (March 2014 updated wederstand the dacument updated in March 2015 to be Ihe current version in force V,1) We Grcorporated into the LASIMPS Joint Memorandur %f Understanding by end and i8 to ba review process. Nevertheless the Deputy December 2015, in accordance with the annual wll Direetorof Operations, Control Services and Deputy Director of Nursing and Quality_ ne policy and its impact for ihe LAS at the next quarterly meeting of the LAS / MPS discuss Joint Working Group on 13 November 2015. The METDG Standard Operating Procedure "Procedure for the Assessment of Ambulance afro rpoeaietropotican Police Service via CAD Link" V.5.0 issued on 18" Regrueaty Zeceived fprovidedMetropottachmentto the Serious Incident Investigation Report 59brisa2020155617 PrZVjdre 2011 Which included guidance on the managerent 0f police STEIS risk patient groups and no reply on ring back (paragraphs 6.1 and 6.22) The calls to hlgh the MPS welfare checks policy, and s0 as an interim meagure and: guidance did not include_ Control Services Bulletin will be Issued at the prior to the meeting on 13 November 2015,& yet _ given

15/09/2015 15:56 02077832009 LAS_LEGAL PAGE 03/03 checks policy to mitigate the risk of a call to end of September 2015 about the MPS welfare clinician patient closed prior to assessment by a vulnerable the Director of Operations, who is the Truars strategic Following this Regulation 28 Report; and the Director of Nursing and Quality, Who operational lead for LAS MPS working mental health and safeguarding with: is eesponaibleafor Strategic and policy liaison regaeliner to be reviewed and clarified to ineeMiposhave asked for our joint meeting arearobugeard ch bethevieweds represented at a eesure thatathe governarce arrangements are robust appropriate level In the future_ to Anne's family and to apologise for the In closing should like to oifer med irohdolerhe Sterioug encident Investigation Report dated ? shortcomings that were identified in the In the do hope too that this reply will be June 2015, which was shared with Vou Arneakeamdvaddre one tnatters of concern: helpfuil in explaining the action taken and being taken Yours sincelrely, Dr Fionna Moore Service NHS Trust Chief Executive London Ambulance being and joint and Joua

Report sections

Investigation and inquest

On 5th February 2015 the Senior Coroner commenced an investigation into the death of Anne Wilson; aged 59 years: investigation concluded at the end of the inquest on gth July 2015. Miss Wilson admitted to some suicidal ideation during her admission to the Hospital. She showed signs of improvement and was discharged with a care package. She failed to attend a scheduled appointment and a welfare call to the police on 2nd February was downgraded_ The conclusion of the inquest was Suicide; Miss Wilson was discovered deceased at her flat on 3rd February and the medical cause of death was hanging

Circumstances of the death

Miss Wilson had a 10 year history of depression. In December 2014 she was admitted to the Priory Hospital with some suicidal ideation. She showed signs of improvement and was discharged on 29 January 2015 with private care package. She had capacity and did not meet the criteria for assessment for detention under the Mental Health Act, Miss Wilson did not attend an out-patient appointment on 30th January 2015 and she was contacted by her Consultant by telephone_ Following lengthy discussion about her well-being, further appointment was made for February 2015. She did not attend and her Consultant was unsuccessful in her attempts to contact her that day: The Consultant contacted Miss Wilson's G.P that afternoon and raised her concerns_ The G.P was also unsuccessful in attempts to contact Miss Wilson by telephone and home visit: He telephoned the police at 16.29 raising his concerns for Miss Wilson's welfare and requesting forced entry. He gave mobile telephone number upon which he could be contacted. The GP was informed that the would attend Miss Wilson's flat within the hour. The MPS informed the LAS that the welfare request had been downgraded under their new policy and that would not attend but did not inform the G.P, The MPS did not pass on the G.P's mobile telephone number to the LAS and the LAS experienced difficulty making contact with the G.P via his surgery. The LAS contacted the MPS on 2nd February 2015 requesting_the MPS to make_ South London Area Coroner's Office, ST. Blaise Building; Bromley Civic Centre; Stockwell Close, Bromley, Kent BRI 3UH The Priory 2na police they contact with the G.P. but this was not done: The G.P contacted the police on 101 on the morning of 3rd February 2015 for an update and to arrange any follow-up care if that was necessary: The G.P was informed that the police had not attended Miss Wilson's flat The G.P escalated his concerns at 08.42 for Miss Wilson's safety via an emergency call to the police The

Action should be taken

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0293
Date of report: 21 July 2015
Coroner: Sonia Hayes
Coroner area: London (South)

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: 15 Sep 2015 (estimated).

Sent to

London Ambulance Service

Metropolitan Police

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.