Simon Robinson · Prevention of Future Deaths report

On 22 January 2019 I conducted the inquest into the tragic death of Simon Robinson who died at his home address of ████████ on 2 February 2018. I returned a Narrative Conclusion as follows:

Simon Robinson, aged 52, died on 02/02/2018 at his home address 20 Bridge Street, Oxford, being formally pronounced deceased at 15.43 hours.

Simon Robinson had a long-standing mental health history of schizoaffective disorder and was suffering a psychotic episode when at approximately 14.27 hours he stabbed himself in the neck with a kitchen knife causing him to exsanguinate. Given his psychosis at the time he may not have been capable of forming a real intention to end his life. At about 14.27 hours his wife phoned 999 to request police attendance but the call was incorrectly graded resulting in a delayed response at approximately 15.15 hours. Given the likelihood that the injuries were sustained at about 14.27 hours it is possible but not likely that an immediate deployment and a response within 15 minutes may have enabled emergency medical treatment to have prevented his death.

Thames Valley Police were legally represented at inquest. In addition to Mr Robinson’s family, other ‘Interested Persons’ included Oxford Health NHS Foundation Trust (OH). Evidence was collated prior to inquest and a copy of the inquest file was provided to your legal department. The evidence at inquest included oral evidence from the police controller and, importantly, from Chief Superintendent Christian Bunt. Prior to inquest, I was provided with a copy of TVP’s Critical Incident Review dated 17 July 2018 and a written statement of Chief Superintendent Bunt dated 22 January 2019 along with other TVP documentation. I attach a copy of the review and statement for case of reference.

As will be seen from the above, Simon Robinson stabbed himself in the neck while suffering a psychotic episode at his home address on the afternoon of 2 February 2018 and bled to death. ████████ made various telephone calls to TVP and OH. Firstly, ████████ dialled 999 and spoke to the police controller at 14.27 hours and despite her concerns about her safety, she was advised to contact OH which she then did. Her concerns were not immediately escalated at OH either.

I should say that Chief Superintendent Bunt was a helpful and frank witness who provided helpful evidence. I appreciate that this matter raises difficult considerations involving communications between, for example, police and mental health services and also issues surrounding the extent of police powers.

The concern that I have is mirrored in Chief Superintendent Bunt’s statement paragraph 57 where it states that the current partnership agreement does not adequately cover incidents such as this one. The problem is not uncommon situation where a person is experiencing a mental health crisis and there is an imminent need for agencies to respond. If the person is experiencing the mental health crisis is in their home or another private place, police powers are limited. I recognise there is a requirement to work in partnership with other agencies but the primary responsibility to respond when there is a fear for welfare or safety rests with the police. It should be the expectation therefore that the police will respond initially to deal with matters until other agencies are able to respond and take over if appropriate. It is concerning that there is a gap in the partnership agreement for a crisis situation such as this.

I understood from Chief Superintendent Bunt that there was a need to formalise a plan at a strategic level to include consideration at inter-partnership meetings. It would be reassuring if the issue could be reviewed in this way and an action plan or similar agreed.