PFD report

Catherine Mary MORGAN · Prevention of Future Deaths report

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Issued 19 May 2026•Kent and Medway

Report record

Published report and response evidence

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.

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Concerns: 10
Recipients: 3
Responses found: 3
Stated actions: 39

Recipients and published responses

College of PolicingResponse found Metropolitan Police ServiceResponse found South London and Maudsley NHS Foundation TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 10 September 2024 I commenced an investigation into the death of Catherine
Mary MORGAN, aged 37 Years.

The investigation concluded at the end of the inquest on 16th March 2026. The conclusion of
the inquest was Catherine Morgan took her own life whilst suffering from anxiety and
depression

Circumstances of the death

[Please explain the relevant circumstances of the individual’s death, ideally this should be in
no more than 500 words]

Catherine Morgan was diagnosed with mixed anxiety and severe depressive disorder. In July
2024 she left her flat in Lewisham and went to stay with her parents in Wimbledon where she
was seen by a GP, a therapist and a psychiatrist.

On 27th August 2024 Catherine travelled to Eastbourne with the intention of ending her life ████████
████████████████████ Her parents reported her missing to Metropolitan Police Service
(MPS) and it was quickly established by MPS that Catherine was at an intermediate station
when she answered a call made by the police. She was safely brought back home by police
on that occasion.

Catherine was taken to St.George’s Hospital by her parents and was admitted as a voluntary
patient to Lewisham Hospital under South London and Maudsley NHS Foundation Trust
(SLAM)

which was the service provider of her registered address (not the address where she was then
living).

On 4th September 2024 Catherine left the ward at 10.30. This was her first period of
unescorted leave. She had agreed to return to the ward by 12.00. It was only discovered that
she had not returned when her mother attended to take her for lunch at 12.50.

Ward staff reported Catherine missing to MPS at 13.17. Applying the Right Care Right Person
Policy and Affinity Protocol MPS declined to investigate because Catherine’s registered home
address had not been visited. At 13.28 Catherine’s father rang MPS to report her missing,
providing information in relation to the earlier suicide attempt and detailing that she should not
return to the registered address. MPS again declined to investigate.

At 14.02 Catherine’s father again contacted MPS to confirm that she was not at her flat. MPS
passed the case to South West London BCU which covers Wimbledon. The CAD was
returned to the despatch unit to reassign to South East London BCU covering Lewisham.
South East London BCU received the CAD at 14.26, Thrive+ summary recording the risk as
high. The morning Operations Inspector (400) was covering for the afternoon inspector who
was on a training course and marked the CAD for her to review without reviewing it himself.
He was unaware of a number of calls from despatch alerting him to the CAD as he was away
from his desk. When the afternoon operations Inspector arrived she went straight into a
meeting without reviewing the CAD. At 15.39 Catherine Morgan’s father called MPS as there
had been no response by the police. This was passed to the operations room. At 16.02 the
400 was informed of the phone call from Catherine’s father and read the CAD, putting in train
enquiries to establish the level of risk (some of which was already known to the police). The
CAD was graded as high risk at approximately 17.00 and the Missing Persons Unit (MPU)
started an investigation. They received information from a phone trace request approximately
60 minutes later that Catherine's phone was within the Dover area and informed H.M.
Coastguard (HMCG).

MPS notified Kent Police and requested an area search. HMCG mobilised when they were
informed Catherine’s cell site showed her near Dover Castle. Information about financial
transactions confirmed her to be in Dover and at 18.59 cell site data placed her at ████████
████████████████████. A HMCG search team arrived in the area a few minutes
later. A Kent Police resource was despatched at 19.13. HMCG located Catherine Morgan at
the cliff edge at 19.45 and engaged with her. Kent Police arrived on scene at 19.47. Catherine
Morgan jumped to her death at 20.16

The jury found the following failures by MPS possibly contributed to the death:

1. The call handler and despatch team applied the Right Care Right Person policy and Affinity
Protocol too rigidly by not registering previous suicide intention resulting in a delayed
deployment;
2. The Metropolitan Police categorising Catherine as a high risk in an untimely manner;
3. Internal communication:
a) didn't utilise existing information held within all available CADs which resulted in delays to
the investigation
b) No inspector cover during senior leadership team meeting policy
c) Lack of prioritisation policy

The jury also identified non-causative failures by SLAM ward staff:

1. Unescorted leave not signed out by registered mental health nurse;
2. Nurse in charge unaware Catherine had been given unescorted leave;
3. Ward staff unaware Catherine had not returned from leave at 12.00/12.30;
4. General observation sheet incorrectly recorded.

Coroner’s concerns

Re: South London & Maudsley NHS Foundation Trust:

It is recognised that the Trust has identified and put in train work that needs to be undertaken
to address the issues that arose at the inquest. Much of the work has not yet been
implemented or is not yet complete and until this is done the following remain as concerns:

1. Evidence was given at the inquest that although dynamic risk assessments were undertaken
in advance of leave being authorised, risk assessments were not consistent with NICE
Guidelines;

2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed. Documentation in respect of leave was incomplete
and did not comply with policy. The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted;

3. The system for monitoring leave was inadequate, reliance being placed on hourly checks.
The nurse conducting the hourly check at 12.00 when Catherine was due to return was not
aware that she was on unescorted leave and did not escalate the matter to the nurse in charge
with the result that the ward only became aware that she had not returned when her mother
arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given
to the patient before escalating the fact of them not having returned, with patients being given
30 minutes or more;

4. Ward staff appeared to take a different approach to leave and return depending upon the
status of the patient as a detained or voluntary patient;

5. A photograph of the patient was not included in the grab pack. Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient

Re: Metropolitan Police Service:

It is recognised that MPS has identified and put in train procedures to address the issues that
arose at the inquest particularly in relation to the approach of MPS following a decision to
transfer a CAD to the BCU MPU. The following remain as concerns:

1. An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted
in a delayed deployment. Even where call handlers have real concerns that someone not
returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to
deploy is the same if the individual's address has not been visited, even when told that they
would not go there. The way in which the policy was applied removed any discretion by call
handlers and dispatchers to deploy whilst checks at the address were being conducted.
Evidence was given at the inquest that the call handler in the second call to MPS attempted to
convey her concerns that there should be immediate deployment to her supervisors in
despatch and was advised the police would not deploy;

2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there;

Re: College of Policing:

It was recognised by MPS at the inquest that there was an overly rigid approach to the Right
Care Right Person policy and Affinity Protocol resulting from the robust application of the
policy and protocol (see above). Some changes have been made within MPS within the
parameters allowed given national guidance and standards, but evidence was given to the
effect that training as to the application of the policy, protocol and toolkit could result in the
professional judgement of call handlers/despatchers/supervisors being restricted resulting in
delays to deployment

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised10

Failure to use a viable welfare-check pathway when the resident is not known to be at the address
Part of recurring concern: Unreliable welfare-check processes for people whose health is of concern Part of recurring concern: Unreliable welfare-check request handling and follow-up
Overly rigid application of deployment policy and affinity protocol
Failure to inform the nurse in charge about leave decisions and circumstances

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 31

Action
Disseminate updated guidance to all forces and support implementation through communications, practitioner briefings and national Tactical Delivery Board input.
Stated by College of PolicingStated planned
Action
Engage forces to understand how guidance is interpreted regarding professional judgement and deployment thresholds.
Stated by College of PolicingStated completed
Action
Publish the revised guidance after completing the ongoing review.
Stated by College of PolicingStated planned

Action
Revise the national Right Care Right Person toolkit to reinforce professional judgement, prioritise vulnerability and life-threatening risk, and prevent undue deployment delays.
Stated by College of PolicingStated planned
Action
Review Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
Stated by College of PolicingStated in progress
Action
Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
Stated by College of PolicingStated planned
Action
Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
Stated by College of PolicingStated completed
Action
Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
Stated by Metropolitan Police ServiceStated planned
Action
Incorporate updated national guidance into training, briefings and supervisory processes for consistent risk-led decision making.
Stated by Metropolitan Police ServiceStated planned
Action
Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
Stated by Metropolitan Police ServiceStated planned
Action
Review control-room escalation arrangements for timely reassessment and specialist advice when vulnerability or risk of serious harm increases.
Stated by Metropolitan Police ServiceStated planned
Action
Review and update local policies, procedures and control-room practices to align Missing Persons policy with Right Care, Right Person.
Stated by Metropolitan Police ServiceStated planned
Action
Support operational discretion for early deployment where risk justifies it and reinforce escalation pathways for high-risk missing persons.
Stated by Metropolitan Police ServiceStated planned
Action
Reinforce risk-based deployment expectations through guidance, supervisory oversight, escalation and reassessment of new information.
Stated by Metropolitan Police ServiceStated in progress
Action
Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
Stated by Metropolitan Police ServiceStated in progress
Action
Review application of the Right Care, Right Person policy across Contact, Command and Control functions.
Stated by Metropolitan Police ServiceStated in progress
Action
Strengthen audit and governance processes to monitor Right Care, Right Person application in vulnerable or high-risk cases.
Stated by Metropolitan Police ServiceStated planned
Action
Review guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
Stated by Metropolitan Police ServiceStated planned
Action
Maintain governance oversight of disputed, complex or high-risk deployment decisions through the expanded Right Care, Right Person Governance Board.
Stated by Metropolitan Police ServiceStated completed
Action
Issue and disseminate a Blue Light Bulletin reinforcing prompt checks and escalation when patients fail to return from leave.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Replace paper hourly observation checks with electronic well-being checks linked to leave monitoring and audit processes.
Stated by South London and Maudsley NHS Foundation TrustStated planned
Action
Provide reflective learning on nurse-in-charge responsibilities for leave management, risk escalation and patient safety.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Develop a standardised leave log suitable for detained and informal patients.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.
Stated by South London and Maudsley NHS Foundation TrustStated in progress
Action
Adopt a personalised, NICE- and NHSE-aligned approach to risk formulation, management planning and safety planning.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Update mandatory clinical risk training to reflect the revised risk assessment and harm management policy.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Review and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.
Stated by South London and Maudsley NHS Foundation TrustStated in progress
Action
Publish and disseminate patient-safety learning on informal leave management, documentation and failure to return to relevant staff.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Investigate and explore producing the leave form electronically, including with the new EPR provider, to improve access, recording and monitoring.
Stated by South London and Maudsley NHS Foundation TrustStated in progress
Action
Introduce and maintain a ward whiteboard recording patient leave and expected return times.
Stated by South London and Maudsley NHS Foundation TrustStated completed
Action
Implement electronic ward-round templates for documenting leave discussions, risk considerations, plans and actions and sharing them across multidisciplinary teams and shifts.
Stated by South London and Maudsley NHS Foundation TrustStated completed

Respondent positions 3

Position
Healthcare providers must undertake initial reasonable enquiries when a patient leaves a healthcare setting, using the most appropriate agency or agencies.
Stated by Metropolitan Police ServiceRedirects responsibility

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 8

1
Work with health and care partners to promote early risk identification, assessment and management through appropriate health, safeguarding and care powers.
Stated by College of PolicingStated planned
2
Implement Local Missing Hubs on each Basic Command Unit with dedicated trained officers, investigative capacity and strengthened supervision.
Stated by Metropolitan Police ServiceStated in progress
3
Promote consistent understanding that vulnerable individuals’ safety is the primary consideration in decision making.
Stated by Metropolitan Police ServiceStated planned
4
Engage with national partners on guidance concerning the overlap between Right Care, Right Person and Missing Persons policy.
Stated by Metropolitan Police ServiceStated in progress
5
Implement an electronic multidisciplinary handover tool that consolidates current clinical, risk and legal-status information and prompts complete handover documentation.
Stated by South London and Maudsley NHS Foundation TrustStated completed
6
Work with the National Confidential Inquiry into Suicide to learn from and share experience supporting personalised risk assessment.
Stated by South London and Maudsley NHS Foundation TrustStated in progress
7
Provide clinicians access to NHS England training on staying safe from suicide and add it to mandatory training using a staggered rollout.
Stated by South London and Maudsley NHS Foundation TrustStated in progress
8
Update the electronic risk assessment tool to warn against predicting suicide risk and capture user acknowledgement.
Stated by South London and Maudsley NHS Foundation TrustStated completed

Recipient positions 1

1
Further ePJS risk-assessment changes are constrained by a change freeze while the Trust moves to a new electronic patient-record provider.
Stated by South London and Maudsley NHS Foundation TrustUnable to act

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised10

Failure to use a viable welfare-check pathway when the resident is not known to be at the address

Overly rigid application of deployment policy and affinity protocol

Failure to inform the nurse in charge about leave decisions and circumstances

Failure to include a patient photograph in the grab pack

Inadequate monitoring and escalation of patients on leave who do not return

Lack of a voluntary-patient checklist for measures taken to locate the patient

Failure to conduct leave risk assessments consistently with NICE Guidelines

Inadequate communication and recording of leave decisions

Training that restricts professional judgement in deployment decisions

Inconsistent approach to leave and return for detained and voluntary patients

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.31

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

Actions described in response 31

Respondent positions 3