Anthony Robert CARD · Prevention of Future Deaths report

On 04 December 2023 I commenced an investigation into the death of Anthony Robert CARD aged 48.

The investigation concluded at the end of the inquest on 06 November 2025.

The conclusion of the inquest was:

Narrative Conclusion - Tony died by way of Suicide

The medical cause of death was confirmed as:

1a Suspension by Ligature
1b
1c
1d
2

The Jury's findings on the questions of how, where and when Anthony Robert CARD ('Tony') came by his death were:

"Suspension by ligature.
Between about noon on 21 November 2023 and about noon on 22 November 2023,
15 Duke Street, Ipswich."

The relevant circumstances for the purposes of this report are as follows:

(a) Shortly before noon on 21 November 2023, Tony was dropped off outside the hotel at which he was staying, at 15 Duke Street, Ipswich, by two police officers.

(b) These police officers assessed Tony as not appearing to be both suffering from mental disorder and in immediate need of care and control. They decided that they therefore did not have power to detain Tony under section 136 of the Mental Health Act 1983. The police officers also considered that they had no other legal power to interfere with Tony's liberty at the time he left their company.

(c) One of these police officers, after their interaction with Tony, submitted a 'Protecting Vulnerable Persons' report ('PVP') on police computer systems. In this report, he described the risk to Tony as a Medium risk, as he said in evidence, he considered that there was some risk to Tony associated with his mental health; but it was not a High risk as Tony was not in need of immediate care and control.

(d) Both front-line police officers in this case understood the PVP to have the effect of communicating, via the Multi-Agency Safeguarding Hub ('MASH'), the information about Tony's contact with police that day to the appropriate agencies who could contact Tony in due course in 'slow time', if they deemed it appropriate, to offer him support. These agencies would include Tony's primary / secondary medical / mental health care providers, bearing in mind that Tony lived in Doncaster and so would not be under the care of any Suffolk NHS Trust.

(e) I subsequently received evidence from Suffolk Constabulary that both officers were in fact mistaken in their understanding that a PVP, concerning a Medium risk to self from mental ill-health, would be communicated on to other agencies via the MASH.

(f) From the evidence received, including a statement from Detective Chief Inspector ████████ of Suffolk Constabulary, it appears that in fact there is no mechanism that facilitates such communication.

(g) DCI ████████'s statement explained that:

"MASH will process adult mental health-related referrals from police only if the individual has care and support needs that meet the threshold for a Section 42 enquiry under the Care Act 2014.

"A care and support need goes beyond a mental health concern alone. It refers to situations where an individual’s ability to live safely and independently is compromised because they cannot meet essential daily living tasks without help. For example, an adult with severe depression who is also neglecting personal care and living in unsafe conditions, or a person with dementia who cannot manage medication or nutrition and is at risk of harm."

Referrals to MASH that do not meet this threshold "are not shared with partner agencies. This approach has been jointly agreed by Suffolk Police and Adult Social Care".

"[T]here is no referral pathway through MASH for mental health support outside safeguarding criteria."

Outside of situations where section 42 of the Care Act 2014 applies, there appears to be no mechanism available to enable front-line police officers who wish, of their own volition and with the subject's consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers, whom may be the right person or agencies to provide support in the medium term.

The information that an individual has, for example, been reported as presenting in such a way that police have had to consider detaining them under section 136 of the Mental Health Act 1983 could be important risk information that would assist medical or mental health care providers.

Not having this risk information available in future assessments may adversely affect decision-making - e.g. not having this information available could contribute to a decision not to admit compulsorily the patient for mental health care if they were to present again in, say, one week from the police interaction.

If such risk information is not received by treating medical or mental health care providers, there may be omission to offer vital further mental health support.