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Investigation and inquest
On 30 August 2016 I commenced an investigation into the death of Terence Joseph Pimm. The investigation concluded at the end of the inquest on 21 April 2017. The conclusion of the inquest was a narrative conclusion
Circumstances of the death
On 26 August 2016, Mr Pimm leapt from the 7th floor of the carpark at Southway Colchester. His death was confirmed there. At the time of his death he was wanted for failing to appear at court in the Metropolitan Police area. On 8 August he had been detained at Romford police station under s136 MHA and taken to Goodmayes Hospital. On 25 August he met with his probation officer and made 3 threats to jump off a carpark. He was taken to A and E at Colchester Hospital, he was not assessed because he was under the influence of alcohol. He was collected by his mother and the next day he did not, as promised, hand himself into the police but went to the carpark.
Coroner’s concerns
1). Call handling and record-keeping at The Lakes
2). Call handling and record-keeping at the police custody suite
3). The sufficiency of guidance and training.
4). To police call handlers as to whether an individual is, objectively, at an “immediate” risk.
5). To mental health assessors as to the circumstances in which the input of family Members should be sought.
6). The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.
7). Training/guidance for mental health clinicians in relation to persons who are subject to a warrant. The evidence pointed to a lack of understanding as to the effect of a warrant upon the clinician’s ability to assess and treat.
Information checked against the published report and official responses