This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On the 13th of May 2011 I commenced an investigation into the death of Stephen Peter Church. The investigation concluded at the end of the inquest on 1st of July 2014. The conclusion of the inquest was a Narrative as attached.
Circumstances of the death
Stephen Church was found dead at the entrance to the multi-storey car park at the Royal Berkshire Hospital on the 13th of May 2011. He had actively sought to take his own life that morning and having been detained by British Transport Police officers under section 136 of the Mental Health Act 1983. He managed to abscond and take his life.
Coroner’s concerns
(1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church. (2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley Area" (3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly. There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised4
Lack of joint working to address high self-harm risk promptly
Insufficient knowledge and understanding of the interagency mental health working protocol
Breakdown of the British Transport Police chain of command for detention responsibilities
Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.16
Action
Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.
Stated byThames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.
Stated byThames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.
Stated byThames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Work with partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.
Stated byThames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Include proactive interagency dialogue requirements in relevant BTP training.
Stated byBritish Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
Stated byBritish Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Implement any Independent Police Complaints Commission recommendations concerning the officers’ actions and promulgate resulting lessons throughout the force.
Stated byBritish Transport PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Disseminate the revised protocol to senior staff and crisis-care personnel across participating agencies.
Stated byRoyal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Hold interagency meetings to identify knowledge gaps and improve joint working on Section 136 patient care.
Stated byRoyal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Consult agencies on the revised interagency Section 136 protocol before requiring participating agencies to sign it.
Stated byRoyal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
Stated byRoyal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Display the approved Section 136 flowchart prominently in the A&E department.
Stated byRoyal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Provide cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
Stated byRoyal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
Stated byRoyal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
Stated byRoyal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
Stated byRoyal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7
Position
Responsibility for disseminating and training staff on the protocol lies with the individual organisations, not Thames Valley Police.
Stated byThames Valley PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The chain-of-command breakdown was an isolated misconduct incident, not evidence of a systemic failing in British Transport Police processes.
Stated byBritish Transport PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Health professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.
Stated byBritish Transport PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.
Stated byBritish Transport PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.
Stated byRoyal Berkshire NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for the police chain-of-command concern lies with British Transport Police, which is addressing it separately.
Stated byRoyal Berkshire NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
British Transport Police cannot sign local protocols because it is a national force, but has agreed to abide by the protocol.
Pin
Get email alerts
Request correction
Information checked against the published report and official responses