Philip John BATTLE · Prevention of Future Deaths report

On 25 July 2022 I commenced an investigation into the death of Philip John BATTLE aged 73. The investigation concluded at the end of the inquest on 25 November 2022. The conclusion of the inquest was that: Mr Battle died by suicide

Philip John Battle lived in warden supervised sheltered accommodation. On the 8th July 2022 he phoned the North West Ambulance service at 11.20. The call indicated an overdose and self-harm by hanging. From the triage protocol then in use this was graded as a category 3 response. This should have resulted in a response within 120 minutes. An ambulance arrived at his secure flat at 15.08 and found Mr Battle had died. He had a ligature around his neck ████████. He was certified as having died at 15.10. It remains unclear as to at what time Mr Battle died.

Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.