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Investigation and inquest
On 29 July 2020, I commenced an investigation into the death of Agnès Blandine Marthe Marchessou. The investigation concluded at the end of the inquest on 25 November 2020. I made a narrative determination, which I attach.
Circumstances of the death
Agnès Marchessou ████████. She had suffered fragile mental health for the four or five years leading up to her death.
On 4 July 2020, she was arrested for assault following a domestic incident. On 8 July 2020, she was knocked over by a bus. Police and ambulance services attended and she was conveyed to hospital.
Coroner’s concerns
Metropolitan Police Service officers attended Ms Marchessou on 8 July 2020, after she had been knocked over by the bus.
1. One of the police officers interviewed the bus driver, who told him that Ms Marchessou had stopped when the bus driver sounded his horn, but then had stepped straight in front of the bus, and after she had been hit had got up and run in front of another bus, only being saved when a passer-by grabbed hold of her.
The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital.
2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children.
The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses.
3. The two police officers waited with Ms Marchessou at the hospital for well over two hours, but did not at any point during that time radio police control to ask for any enquiries or searches of police systems to be made.
Such information could have been potentially extremely helpful to those treating Ms Marchessou.
4. When the police officers returned to the police station, they did make a search themselves and discovered that she had been arrested for domestic violence. However, they did not make a Merlin record of her potential vulnerability and need for assistance.
5. I was provided with a statement from one of the two police officers in advance of the inquest and I called him to give oral evidence on 25 November 2020. When I put to him the suboptimal nature of the way that he had dealt with the incident on 8 July 2020, he did not appear to have undertaken any reflection on this in the intervening four and a half months, nor in the witness box.
If there was any error in not passing on information, he attributed this error to his colleague. He did not consider that he had failed to apply a healthy degree of scepticism to Ms Marchessou’s version of events, particularly in the light of the bus driver’s description. He reiterated the view he had formed on the day, that Agnès Marchessou being hit by a bus was purely an accident.
The police officer defended all of his actions robustly. I could not see that he had learnt anything as a result of these events or that anything about his practice would change in the future.
6. The police officer giving evidence was aware of the view of the Directorate of Professional Standards (DPS) regarding the failure to create a Merlin, expressed in its report on the police handling of the incident on 8 July, but he seemed very confused about how that should work in practice.
If he is confused, even after police have taken him through the DPS report, then other police officers may also be confused.
Information checked against the published report and official responses