Mark Harris · Prevention of Future Deaths report

On 7 January 2019 I commenced an investigation into the death of Mark Harris, aged 24. The investigation concluded at the end of the inquest on 16 January 2019. The conclusion of the inquest was that the death was a misadventure with a medical cause of death of asphyxia due to hanging contributed to by his mental health, the communication of bad news by his AFCAS Officer that morning, the volatile relationship with his ex and the communication failure between the ambulance service and police, and between the police control room and attending officers.

On 11 January 2016 Mark Harris was found deceased with a rope around his neck at the home of his ex-partner where he was residing at the time.

Mr Harris had been taken into police custody between 8 & 10 January 2016 for amongst other things common assault against his ex-partner and breach of bail conditions to attend her property. Upon his release he went home to his ex-partners address where he was living alone, with her agreement. He messaged his ex that evening and threatened to kill himself if he could not be with her. He had a history of self-harm and was well known to the police. When nothing was heard from him the following day his ex called 999 for a welfare check at about 1.40pm. The ambulance service requested the attendance of police when the ex-partner indicated that he could be violent. The ambulance service graded the call for attendance within 30 minutes.

The police initially attended around 2.30pm leaving at 3.10pm, and then again after 5pm. They requested additional information from the ambulance service and their own control room to identify the occupant of the property. They were unaware that the ex-partner had said he was definitely in the property and unaware that she had a key and was only 30 minutes away. Neither were they made aware of the recent custody or the conditions of bail when they told the control room that they suspected it was Mark Harris and not Hais. The ambulance service first attended at 4.38pm due to the heavy demands on the service that day, but there was a further delay in gaining access to the property until the ex-partner attended with the key around 5.10pm. Mr Harris was found to have ligatured. The ambulance service recognised life as extinct immediately.

The police believed that they had been asked to conduct a welfare check on a Mr Hais.

(1) The 999 call was directed to the ambulance service for a welfare check. The suicide protocol was initiated by the call handler to seek information. When the police were called the mis-spelt name of the deceased as HAIS was provided to them together with detail of the nature of the welfare call as “messaging all night threatening to kill himself”. The police attended the address. Had the correct spelling of the name been provided to the police they would have known Mark Harris and his history of suicide attempts. This was a significant problem for an intelligence led service.
(2) It was unclear to the police that they were being asked to attend to safeguard ambulance personnel and not to undertake a welfare check. The protocol used by the call handler did not make provision for that to be stated.
(3) The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD.
(4) There is no agreed protocol between the ambulance and police services facilitating communication to formulate an ambulance service protocol which incorporates information helpful to the police.