Ronald Bainborough · Prevention of Future Deaths report

On 4 October 2023, Assistant Coroner Smith commenced an investigation into the death of Ronald Bainborough aged 52 years. The investigation concluded at the end of the inquest on 15 July 2024. The jury made a natural causes conclusion supported by a narrative, which I attach.

I drafted this report in early October 2024. However, it was not issued at that time owing to an IT error.

Mr Bainborough lived in supported living accommodation. He had a history of schizophrenia and substance misuse but had been discharged from mental health services in 2022 due to poor engagement. Mr Bainborough was not taking anti-psychotic medication and did not engage with his GP. Mr Bainborough’s mental health problems contributed to him being visibly underweight. Attempts were made to assess Mr Bainborough’s physical and mental health, but Mr Bainborough refused to engage. Following a failed attempt to informally assess Mr Bainborough under the Mental Health Act on 5 June 2023, it was decided to apply for a warrant under Section 135(1) Mental Health Act so that Mr Bainborough could be detained to enable an assessment to take place. There were significant delays in applying for a warrant for reasons specific to the circumstances of this case. An application for a warrant was submitted to the Magistrates Court on 18 August 2023 and the warrant was granted at a hearing on 23 August. Once a warrant was issued, an appointment was made for police officers to execute the warrant on 7 September 2023. Before the warrant could be executed, Mr Bainborough was admitted to hospital on 29 August 2023 suffering from malnutrition. He had a BMI of around 13. He was detained under Section 2 of the Mental Health Act. The plan was for him to receive physical and mental health treatment in an acute hospital setting until he was physically well enough to be transferred to a psychiatric unit. Mr Bainborough died on 11 September 2023. The medical cause of his death was: 1a) community acquired pneumonia and malnutrition; 1b) anorexia and chronic schizophrenia; 2) chronic obstructive pulmonary disease. The Jury found that the delay in applying for a warrant may have affected the outcome for Mr Bainborough.

(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed

(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.

(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.

(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.

(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.

(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.