Source · Prevention of Future Deaths

Suzanne Cammell

Ref: 2014-0579 Date: 28 Jul 2014 Coroner: Darren Salter Area: Oxfordshire Responses identified: 1 / 2 View PDF

Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.

Date 28 Jul 2014
56-day deadline 22 Sep 2014 est.
Responses identified 1 of 2
Police related deaths

Coroner's concerns

AI summary
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.
View full coroner's concerns
In the circumstances it is my statutory duty to make this report to you.

The MATTER OF CONCERN is as follows:

(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/ or the driver in time.

This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and would have had access to.

The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to and his colleague carrying out the welfare check at approximately 03.30. The evidence of at Inquest is that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment.

also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unify” Intelligence database.

The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to .

I appreciate that carried out a prompt welfare check and that Ms Cammell’s presentation was such that did not consider her to be at risk but it appears he did not have available crucial information.

Responses

1 respondent
Thames Valley Police Police / Law Enforcement
28 Jul 2014 PDF
Noted

Thames Valley Police reviewed the communication between their control room and Gloucestershire Police regarding the deceased. They clarified the information that was shared and noted that Gloucestershire Police had previous knowledge of the deceased's mental health issues. They have also put measures in place to address information sharing between the Professional Standards Department and the officer who prepared the report. (AI summary)

View full response
Dear Mr Salter. Thank you for your letter of 28 July 2014 in respect of the issue of a Regulation 28 Report following the Inquest touching the death of Ms Suzanne Cammell. note that that the issue of concern for TVP appears to relate to communication between this force and Gloucestershire Police and that; in particular; "specific information, of a high risk nature; was not or may not have been passed by TVP to Gloucestershire Police or, if it was, it may not have been made available to understand that, at Inquest, you did not have available to you details of the specific information passed by TVP Control Room to Gloucestershire in the early hours, which subsequently led t0 of Gloucestershire and his colleague carrying out the welfare check gather therefore that the concern is that while based on the information TVP , carried out a prompt welfare check, he might not have had information which could have affected his decision in relation to the degree of intervention required_ of our Professional Standards Department has carried out a thorough review of this matter; in the course of which he has consulted with senior colleagues from the Control Room & Enquires Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health) With reqard to the question of the information passed from TVP to Gloucestershire, ffindings may be summarised as follows from

On Thursday 3r October 2013 at 0120hrs TVP was notified that an elderly female was wandering_around on her own in the direction of Burford town centre. The caller was concerned for her welfare_ At 0122hrs it was recorded thatl stated that Ms Cammell was trying to under lorries parked up in a lay-by: He had woken her and she had walked off. 2 attended and found Ms Cammell hiding behind a hotel, her explanation being she was scared of people who were following her: These were established to be and his 2 friends accepted that response but, being concerned for Ms Cammell's well-being: spoke to her at length. She found her to be at no immediate risk and also identified that she had her car_ a silver Jaguar, parked in the lay-by: was joined by and and it was decided that for Ms Cammell's own safety land Ishould take her back to her home address of 15 The Stables, Lechlade Gloucestershire. 5 The officers took Ms Cammell home a residential complex where she lived alone. They found her home to be to be clean and tidy and, having no further concerns, they left_
6. At 0230hrs, Thames Valley Police Control Room made contact with Gloucestershire Police Control Room to inform them of the action that had been taken, advising that she had been left alone at home but appeared to be alright At 0245hrs Gloucestershire Police control room contacted Police Sergeant He was asked to view their log and, at 0253hrs, along with anolher officer, he attended the home of Cammell At 0345hrs reported that Ms Cammell was safe and well and that he had no concerns: At 0543hrs of TVP made an additional call to Gloucestershire Police control room as she had been unable to do s0 earlier due t0 other commitments: She told them that, earlier that morning; she had seen Ms Cammell wandering around a course hotel She told Gloucestershire about the circumstances of finding her. enquired with Gloucestershire Police if Ms Cammell was known .0 inem and suggested that they may need to complete an Adult Protection referral_ It would appear that was unaware of the contact between the two control rooms at 0230hrs. 9_ At 0705hrs Thames Valley Police received a call from a member of the public stating that there was & dead woman in the lay-by at Burford and that it looked Iike her head had been run over. The deceased was later confirmed to be Ms Suzanne Cammell_ get Ms golf

10.The Independent Police Complaints Commission was immediately informed and attended the scene; as this was a death following recent police contact. The decision from the IPCC following their scene assessment was that this matter was suitable for local investigation This was dealt with by Jof Thames Valley Police Professional Standards.
11.Enquires later revealed that Ms Cammell had suffered from depression from the age of 19. Furthermore, it was established that on 23rd September 2013, in the Gloucestershire Police Area, Ms Cammell was subject to detention under s136 of the Mental Health Act, having been seen placing her head under the wheels of a lorry. This information had subsequently been recorded in the Police National Database (PND): 12 from Gloucester Police carried out the later welfare check on Ms Cammell and in his evidence at the inquest, said that he was unaware that she had been found lying underneath earlier that night and that if he had know this he would have made arrangements for mental health assessment He also gave evidence that he was unaware of the incident on the 23rd of September , despite the fact it was on the PND and the Gloucestershire intelligence database 13 Treview has examined the call from It found that Told the TVP control room that Ms Cammell had been trying to get under a and records of radio traffic confirm that this information was passed t0 the attending TVP officers_ In his call_ made reference to his waking up the lady as he had concerns that the lorry could drive away with her under the tyres:
14.The call from Thames Valley Police Control Room to Gloucestershire, Police control room also been reviewed It has been established that the TVP officers asked their control room to call Gloucester Police and advise them of the incident involving Ms Cammell 15 The information conveyed to Gloucestershire Police included that Ms Cammell had been found in Burford in confused state and that the informant was concerned as Ms Cammell had been trying to get underneath lorries and that TVP officers had taken her home
16. The TVP call taker was asked what Ms Cammell was like when she was dropped off and replied that it was difficult to say from the log but that there were no medical concerns_
17.It is clear from the conversation between both control rooms that Gloucestershire Police had previous knowledge of Ms Cammell, with their call taker commenting 'Check conducted on name and address. Check revealed the lady has problemslmental health issues' . lorry lorry has

18 During the conversation between the control rooms the Gloucestershire officer said, "Okay, alright then: but you don"t want us to do actually do anything then?' The Thames Valley officer replied Well dont know whether it's worth making your Iocal mental health team aware probably would do that to be honest In summary; it would seem that TVP informed Gloucestershire Police of the concerns as reported by insofar as he hadfound Ms Cammell in a confused state and that she had been trying t0 get underneath a lorry_ Admittedly, information shared did not go into quite the detail reported by] who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying t0 get under one am not sure whether this would have made a material difference to risk assessment when he visited Ms Cammell at home; This would seem to be a matter for Gloucestershire but | hope have at least been able t0 clarify the information that was shared_ understand that you posed to Gloucestershire a question in respect of the use of the Police National Database and that have covered this in their response Furthermore , gather that at the Inquest you expressed concern in relation to a lack of information sharing between the Professional_Standards Department and the officer who prepared the report for you: has put in place measures to address this He has taken the liberty of making an appointment with you on November 2014 to brief you on these measures and, of course, deal with any further questions you might have in respect of the case of Ms Cammell. trust this has been of assistance but please do not hesitate to make contact should you require any further information Sara Thornton Chief Constable the they

Report sections

Investigation and inquest
On the 14 October 2013 I opened an Inquest into the death of Suzanne Cammell, aged 71, who died on 3 October 2013 at a layby on the A361 near Burford Golf Club. I concluded the case at Inquest on 16 July 2014 at Oxford Coroner’s Court. A copy of the Record of Inquest is attached. It will be seen that I gave a conclusion of Suicide and stated that…

”At approximately 06.00-07.00 hours on 3 October 2013 Suzanne Cammell lay underneath the wheels of a lorry trailer parked in a layby on the A361 near Burford Golf Glub and was killed instantly when the lorry drove off at approximately 07.00 hours.”

An investigation was initially carried out by TVP and a file of papers was submitted to me. There was oral evidence from of Gloucestershire Constabulary, TVP Officers and from Mental Health Professionals.
Circumstances of the death
The circumstances of the death may be known to you. A copy of the Inquest file was disclosed prior to the Inquest. Consequently, I have not provided you with a copy of the Inquest file with this report.

At approximately 01.20hours on 3 October 2013 a call was made to TVP by the owner of a kebab van situated in the layby on the A361 near Burford Golf Club. He reported that he was concerned about a woman in the layby (Suzanne Cammell) who was seen lying or trying to lie under a lorry parked in the layby to go to sleep. He went on to say that he woke her up when he saw her under the lorry as he was concerned she may get run over in the morning.

TVP Officers attended. and took Ms Cammell and her vehicle back to her home in Lechlade. They left her at her home address at approximately 02.20. There was communication between TVP and Gloucestershire Constabulary and at about 03.30 and another Gloucestershire Officer attended and spoke to Ms Cammell at her home to check on her welfare. The Gloucestershire Officers then left.

According to CCTV footage at Burford Golf Club, it appears that Ms Cammell returned and parked her car up in the grounds of the Golf Club at approximately 05.30. At 07.00 hours the lorry in the layby (the only one parked there overnight) drove off. Ms Cammell appears to have been lying underneath the wheels of the lorry and sustained devastating crush injuries to her head, chest and abdomen. The medical cause of death from the Pathologist, , was severe blunt head injuries.

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Report details

Reference
2014-0579
Date of report
28 July 2014
Coroner
Darren Salter
Coroner area
Oxfordshire

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: 22 Sep 2014 (estimated).

Sent to

Thames Valley Police
Gloucestershire Constabulary

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