Dear Mr Bedford: Ref: PJB Church am writing in response to your request for explanation about what action Thames Valley Police proposes to take following receipt of the Regulation 28 report from Assistant Coroner Mr Ravi Sidhu; who presided over the inquest into the death of Mr Stephen Church: Thames Valley Police were not directly involved in the original incident involving Mr Church, his detention under S136 Mental Health Act nor his subsequent care prior to his death on 13th
2011. However, as the force lead in Mental Health for Thames Valley Police take responsibility for CO- ordinating the publication of an interagency joint working protocol for managing mental health in the Thames Area: This protocol was subject to discussion during the inquest. The interagency protocol is drafted in consultation with all the statutory partner organisations and once completed is signed by the Chief Executives or Heads of Service for each agency_ Re-drafting of the current protocol has been waiting for the publication of the Crisis Care Concordat from the Department of Health and actually also the findings of this inquest: The new draft relating to detention under S136 MHA is now in the consultation phase and will take into account all the elements of the incident that resulted in the death of Mr Church. In addition to this the Chief Executive of Berkshire NHS Foundation Trust, Mr Julian Emms, has already consulted with relevant organisations to agree a May Valley

local declaration and action plan to meet the expectations of the Crisis Care Concordat Thames Valley Police will be signatories to this declaration once agreed_ The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric Iiaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However; once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities While British Transport Police have indicated that they are unable to be signatories to individual protocols as a National Force, Thames Valley Police will make every effort to ensure their awareness and understanding of the Thames Valley protocol. If you require any further information please do not hesitate to contact me.

BRITISH TRANSPORT 22 August 2014 POLICE Yeomanry House 131 Castle Hill Reading Berkshire RG1 TTA Aen sun Botfotdt, Inquest into the death of Stephen Peter Church Report to prevent future deaths have been asked by the Chief Constable in his absence, to respond to your letter dated 17th in relation to the Regulation 28 Report highlighting concerns following the inquest into the death of Stephen Church. You will appreciate that this tragic incident occurred in 2011 and since that time the force has made great improvements in how it deals with vulnerable people: We have received much praise for our suicide prevention work and our partnership working in this field is pioneering in policing terms. With regards to the specific circumstances of Mr Church's death have instructed my officers to review the matters of concern: note that the second concern (of three) does not relate to British Transport Police With regards to Concern 1: The chain of command within BTP was broken unacceptably leading to only one police officer responsible for detaining Mr Church: arrived at the Royal Berkshire Hospital about 11.45 with Mr Church was assigned t0 a pre-arranged operation later that and needed to get to London to collect paraphernalia in relation to that operation He wanted to leave the hospital so that he could undertake that task About 12:10 telephoned the Duty_Officer, Temporary Inspector and asked whether could be released. linformed that Mr Church was not under the British Transport Police Force Headquarters, 25 Camden Road, London, NW1 9LN email david mccall@btp:pnn police.uk direct 020 7830 8810 fax 020 7383 3023 July day

BRITISH TRANSPORT POLICE influence of drink or drugs and was compliant: refused the request and instructed that both officers should remain. This message was conveyed to About 12.30 ttelephoned and subsequentlv_sent a text message to his line manager at Reading; Iwas in fact off duty at the time but authorised also by text message, to leave the hospital. was not made aware of this development: As far as he was aware both Iremained at the hospital with Mr Church_ At the_inquest stated that he was not aware at that time that had instructed both officers to remain at the hospital He added that had he been aware he would not have sanctioned departure: conceded in evidence that the text message did in fact include that information but at the time of agreeing to departure he had notread the entire text message, which included recognise that this breakdown in the chain of command ultimately had implications for the care of Mr Church but do not believe that this is a systematic failing in BTP processes: Rather; this was an isolated incidence of misconduct. My Professional Standards Department referred this incident to the Independent Police Complaints Commission in 2011 and we currently await the outcome of that investigation. will ensure that any recommendations in relation to the actions of and lare implemented and that any lessons learned are appropriately promulgated throughout the force_ With regards to Concern 3: There was a lack %f joint working amongst the BTP, Royal Berkshire Hospital and psychiatric Iiaison service staff members to ensure that Stephen Church was safe and the high risk of him self ~harming addressed promptly: There was a lack of appreciation amongst the psychiatric Iiaison service, Royal Berkshire Hospital staff and BTP as to the importance of contacting an approved mental health professional promptly to arrange mental health assessment: note that that was concered at the lack of joint working in respect of Mr Church's detention and treatment: In particular: British Transport Police Force Headquarters, 25 Camden Road, London, NW1 9LN email david mccall@btp pnn police.uk direct 020 7830 8810 fax 020 7383 3023 Jury

BRITISH TRANSPORT POLICE No-one took responsibility for contacting the Approved Mental Health Professional (AMHP): Hospital staff were not aware that BTP officers were with Mr Church and believed them to be from Thames Valley Police. Only one of the BTP officers was aware that Mr Church had been assessed as high risk of self harm. Staff were not aware that one officer was left alone with Mr Church. acknowedge that regular and detailed communication with the other agencies involved in Mr Church's case could have led to his greater care whilst at the hospital: Further; that additional care staff may have been provided had they been aware that he was with only one officer. This issue of 'proactively maintaining dialogue' is covered in the 'Briefing Note New Policy for London Section 136, (page 60) under the heading 'Triage Risk Assessment_Triage Psychiatric Assessment . This element of that briefing note is now included in all relevant BTP training: note that the Jury narrative highlighted the following points; An approved Mental Health Professional should have been called, the fact that one was not called contributed to Stephen Church's death for the following reasons; The protocol states that the AMHP should be called promptly Stephen Church was considered 'High Risk' by police and medical staff The Mental Health Act Codes of Practice clearly states that this is the next step to a Section 136 detainee The delay left his mental health un-assessed The role of the AMHP was t coordinate the agencies and to provide clear direction and this did not take place The Inquest heard evidence that the single most important person to be informed about the detention of a person under section 136 is the AMHP The AMHP has the ability and responsibility to coordinate all other agencies involved in the care of the detainee. As soon as the AMHP is informed all other actions and processes in respect of the care of the detainee can be expedited, thus reducing the amount of time police need to remain at the place of safety: The inquest heard evidence relating to the Mental Health Act;, 1983, Code of Practice especially in respect of paragraph 10.25 which states; (page 21) British Transport Police Force Headquarters, 25 Camden Road, London; NW1 9LN email david mccall@btp pnn police.uk direct 020 7830 8810 fax 020 7383 3023

BRITISH TRANSPORT POLICE Where an individual is removed to a place of safety by the police, the following recommendations apply: Where the place of safety is a hospital, the police should make immediate contact with both the hospital and the LSSA (or the people arranging AMHP services on its behalf) {my emphasis} and this contact should take place prior to the person's amival at the place of safety. This will allow arrangements to be made for the person to be interviewed and examined as soon as possible_ The 'Interagency Joint Working Protocol for the Management of Mental Health, Thames Valley Area' (The Protocol) also deals with the procedure for calling an AMHP: It states, (page 12) 'The arresting officer will contact (via Control Room) the AMHP or the Emergency Duty Team out of hours_ It was acknowledged at the Inquest that British Transport Police was not a signatory to the joint interagency protocol; but officers giving evidence accepted that would to work to the aims where possible_ endorse this aspiration but must highlight the impracticalities of British Transport Police being able to achieve this in every case The recommendation that police should contact the AMHP in these circumstances will always be problematic for British Transport Police. We do not routinely have lists of availablelon call AMHPs This is infomation routinely known to health providers at the places of safety and is likely to be subject of regular change and update, sometimes at short notice_ It would be impractical and problematic for a national police force such as the BTP to hold this" "information and keep it up to date: To attempt to do so could result in more confusion, risk and delay should officers require to contact an AMHP to the subjects' removal to a place of safety: My view is supported by reference to recent meeting of the Mental Health Partnership Board for London, which includes CEOs of the London Mental Health Trusts. At that meeting the question of whose role it was to call the AMHP following a S136 detention delivered a unanimous response; that it was the role of the health professionals as the police would not have access to up to date infomation: The Board has recently launched a new policy for S136 and S135 arrangements in British Transport Police Force Headquarters, 25 Camden Road, London, NW1 9LN email david mccall@btp pnn police.uk direct 020 7830 8810 020 7383 3023 they try prior fax

BRITISH TRANSPORT POLICE London (which was used to inform the Mental Health Crisis Care Concordat to which BTP is one of the 22 national signatories) That policy does not recommend that Police call the AMHP_ The duty on Police is to call the place of safety coordinator who is then responsible for making all necessary arrangements. am aware that the Mental Health Act Code of Practice is currently being reviewed and draft has been circulated for consultation: British Transport Police will be asking for the recommendation for Police to call the AMHP prior to arrival at a place of safety to be removed, as it is impractical and more likely to lead to confusion and delay in provision of an early assessment for a patient in similar circumstances to Mr Church: can assure you that British Transport Police is committed to providing the best possible care to those vulnerable members of society who come to our notice. In terms of the demand we face, can tell you that in 2013/14,631 people were directly prevented from taking their own lives on the railway and removed from danger: Of these the majority were detained under S136 of the Mental Health Act 1983 and presented to place of safety for assessment In more general terms some 150 people per month are currently detained under S136 across BTP jurisdiction and am unaware of any repetition of the issues you have raised. Whilst it would be a vast undertaking to be aware of each and every local protocol from the 56 Statutory Mental Health Trusts and the 40 Mental Health Trust providers in England and Wales, we are nevertheless in the process of detailing all 'places of safety'on our Force Control Room Gazetteer to speed up the process of care for Section 136 detainees. have committed training resources to front-line officers in the following areas: Exercise Jubilee a Hydra (immersive training) exercise in relation to vulnerable persons and those in Mental Health Crisis Suicide Prevention and Mental Health awareness a one day classroom- based programme for all officers around policies and processes as outlined in new manual of guidance British Transport Police Force Headquarters, 25 Camden Road, London; NW1 9LN email david mccall@btp:pnn police.uk direct 020 7830 8810 fax 020 7383 3023 the

BRITISH TRANSPORT POLICE A two hour input t0 all Force control room staff on Suicide Prevention and Mental Health issues; the officer in charge of this training has been fully briefed on the findings from Mr Church's inquest and will incorporate the lessons leamed into this presentation All new officers receive a two hour input from the same officer and again the lessons learned from Mr Church's inquest will be incorporated In summary, the break down in the chain of command is being addressed as conduct issue and am confident that there is no systemic failing in this area: With regards to the other concern highlighted, the BTP Manual of Guidance now includes the following: The original officers and those that may take over supervision of any detainee should ensure that the person is not left alone or unsupervised until the responsibility for the person is formally handed over to medical professional for the process of assessment and interview . In addition to this, the guidance now also makes clear that; 'Attending officers and the senior nurse at the place of safety must consult _ and ensure that the relevant mental health doctor and AMHPs have been advised of the persons status'. feel confident therefore that the concerns highlighted at the Inquest have been properly addressed by British Transport Police. Atous Sscen%a Temporary Deputy Chief Constable British Transport Police Force Headquarters, 25 Camden Road, London, NW1 9LN email david mccall@btppnn police.uk direct 020 7830 8810 fax 020 7383 3023

Dear Mr Bedford Re: Regulation 28 response in the matter of SC (Deceased) The Trust has investigated and acted upon your concerns as set out in the Regulation 28 report to prevent future deaths dated 10 July 2014. Coroner's concerns
1. The chain of command within the British Transport Police have broken unacceptably leading to only one police officer responsible for detaining SC. Z. There was insutficient knowledge and understanding amongst members of the Psychiatric Liaison Service and the Royal Berkshire Hospital as regards the interagency joined working protocol for the management of mental health Thames Valley area.
3. There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and Psychiatric Liaison Service staff members to ensure that SC was safe and the high risk of him self-harming addressed promptly. There was a lack of appreciation amongst the Psychiatric Liaison Service, Royal Berkshire Hospital statf and British Transport Police as the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment. lnteragency meeting on 24 September 2014 ln order to address the coroner's concerns, there was a meeting at the Royal Berkshire Hospital in Reading. In attendance were the following: .
- Director of Nursing, Royal Berkshire NHS Foundation Trust, Corporate Safeguarding Lead. . es
- Berkshirehealthcare NHS Foundation Trust r Royal Berkshire NHS Foundation Trust , Mental Health Coordinator

Royal Berkshire fW$ffi NH5 Foundation Trust .
- Nurse Manager, Psychological Medicine Service, Berkshirehealthcare NHS . Foundation Trust r r - Inspector, British Transport Police r Approved Mental Health Practitioner (AMHP), Reading . Consultant in the Psychological Medicine Service, Berkshirehealthcare NHS NHS Foundation Trust c Consultant in the A&E Department, Royal Berkshire NHS Foundation Trust . Consultant in the A&E Department, Royal Berkshire NHS Foundation Trust r Berkshirehealthcare NHS Foundation Trust r Matron in the A&E Department, Royal Berkshire NHS Foundation Trust The meeting was held to discuss the concerns raised by the coroner. With regards the first area of concern, this is within the control of the British Transport Police and so we did not discuss it in any depth. We understand a separate response has been sent. At the inquest into SC's death on 1 July 2014 (the inquest), the coroner identified concerns regarding an interagency protocol in use at the time. The protocol addresses a number of areas of inter-agency interaction with mental Health patients in the Thames Valley. lt contains guidance on the management of section 136 patients under the Mental Health Act 1983 which was the area of concern identified at the inquest. A revised version of the protocol is currently being finalised by Thames Valley Police under the supervision of , Inspector, Thames Valley Police, and Mental Health Lead"
- s, Mental Health Act Administrator, is also assisting with the revision of the protocol. The intention is for the protocol to be clearer and easier to understandlnavigate so that the agencies can work together more effectively and are able to identify their individual roles with regards patients who are admitted to the Trust under Section 136 of the Mental Health Act 1983. There will be a consultation with all of the key members of the agencies including the senior A&E consultants at the Royal Berkshire Hospita e (mental health co-ordinator at the Trust) and the Psychological Medicine Service (PMS). After the consultation the agencies will be required to sign the protocol. There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it. The Royal Berkshire Hospital has drafted a flowchart to make the A&E staff more aware of the steps that need to be taken in relation to Section 136 patients who are admitted to the accident and emergency department (A&E). At the meeting two classes of patients were identified. There are the patients who are admitted under Section 136 and who are only intended to be at the Trust for acute medical care for a very short period of time but then will be transferred to a place of safety such as Prospect Park Hospital and those like

Roya| Berkshire WSP--S NHS Foundation Trust SC who need prolonged medical care and therefore are likely to be admitted under the Trust's care or transferred to another acute Trust. During the meeting one of the things which was identified as causing a difficulty and which may have caused a difficulty when SC was admitted to the Trust was that there are six areas in the Reading area who all have separate AMHPS. This complicates the process in that the individual informing the AMHP of the need for their assistance when a Section 136 patient is identified is complicated by the fact that the individual concerned needs to be able to identify where the individual patient was when the Section 136 was applied. Depending on where they were physically at the time, a different AMHP might be contacted. This causes some confusion in the system. The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Sectionl36 monitoring form used by the Mental Health Services. There was also an agreement between all of the agencies that there should be closer working together with shared information and assessment forms so that the process works much more safely in the future, Steps taken to address the individual concerns of the coroner are as follows:
1. ln relation to the concern that there was insufficient knowledge and understanding amongst members of the Psychiatric Liaison Service and the Royal Berkshire Hospital with regards the interagency working protocol for the management of mental health in the Thames Valley area, an interagency meeting was held on 24 September 2Q14 to identify the gaps in the various agencies' knowledge and understanding with a plan put in place to revise the current protocol and to hold a consultation. The protocol will be sent to all senior staff involved in crisis management of these patients and there will be training in the use of the protocol for all of the agencles.
2. The trust has a flowchart which identifies the steps that need to be taken from the point of admission to A&E and identifies the role of the psychological medicine service (PMS) at the Trust who will advise A&E on the management of the patient in the A&E Department. They will also check that AMHP has been called which was a particular area of concern. The concern that there was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and Psychiatric Liaison Service staff members has been addressed by putting in place a series of meetings between all the agencies involved and consulting over a revised version of the protocol which will then be sent to all senior members of each agency. lt will be sent to all those involved in crisis care. There will be training on the use of the protocol for all of the agencies who are to sign it including British Transport Police. The lack of understanding as to the process and whose responsibility it is to callthe AMHP will be addressed in three ways. The first is the amendment to the interagency protocol and that is in an advanced state and will be sent for consultation at the beginning of November 2014. There will be training across all of the agencies involved including Thames Valley Police, the Royal Berkshire NHS Foundation Trust (A&E and Psychiatric Liaison Teams), the British Transport Police and AMHPs in the Berkshire area. The Trust has drafted a flowchart that wil be displayed prominently in the A&E department and will identify the process from admission of a patient under a Section 136 to the A&E department to informing the AMHP and arranging for
3.
4.

Royal Berkshire flm"Hffi NHS Foundation Trust the patient to be assessed with either admission to the Trust with support from PMS or a transfer to a place of safety e.g. Prospect Park Hospital. The flowchart has been finalised and approved by the A&E Clinical Governance Team. The Royal Berkshire NHS Foundation Trust has also adopted the assessment forms for Section 136 monitoring from the mental health Trust so that the key information is gathered on admission and the nursing staff are able to identify whether the AMHP has been informed of the need for assessment at an early stage. There will be a further check made by the PMS who will advise the A&E staff regarding the management of the Section 136 patient in the A&E Department. PMS will also check whether the AMHP has been contacted. Copies of the assessment form for Section 136 will be sent to the RBH Mental Health Coordinator so that care can be audited.
5. There is to be an emphasis on the importance of contacting an AMHP promptly which will be communicated to all A&E staff and all A&E staff will be aware that they must assume responsibility for calling the AMHP and/or for checking that they have been contacted and that they understand an urgent need to assess the Section 136 patient at the Trust as quickly as possible. This is also one of the actions included on the flowchart which requires a senior member of staff in A&E to ensure the AMHP has been contacted. The timetable The timetable for the above steps depends on the date when the amended protocol will be available and will be sent out to consultation. We are advised that it will be completed and ready for consultation at the beginning of November
2014. ln the meantime, the Royal Berkshire NHS Foundation Trust has finalised and approved a flowchart that will be prominently displayed in the A&E department. lt is intended that the flowchart will be in place in the A&E department before 26 November 2014 and that staff will have received training with regards use of the ftow chart and the s136 monitoring forms by the end of November 2014. In the meantime, the two senior consultants from the A&E departmen , and the Matro ttended the inter-agency meeting at the Trust on 24 September and have taken the message back to the A&E department that there should be liaison with the PMS at the Trust who, although they will not take responsibility for the patient, will advise on their management and contacting the AMHP if that has not already been done. There is therefore a mechanism whereby the A&E staff will be aware that it is their responsibility to check that the AMHP has been contacted and if for any reason it is not done for the PMS to make sure that contact is made at the earliest opportunity. ln summary, the interagency protocol has been finalised and will be sent out to all the agencies involved for consultation at the beginning of November 2014. There has been a meeting between all of the relevant agencies and another meeting is planned to discuss the revised protocol with training for staff involved in crisis management to follow. The A&E department has a flowchart which has been drafted in consultation with PMS and which makes it clear that an AMHP needs to be called by a senior member of the A&E staff and that PMS should be contacted to advise on management of the patient in A&E. The chart includes the numbers of the 6 AMHPs in the Reading area and will be displayed prominently in A&E from 26 November 2014 at the latest. The Trust have adopted the Berkshire NHS Trust's Section 136 monitoring forms which will encourage a consistent approach. They are to be used in conjunction with the flowchart and also include the information that is needed on admission including whether the AMHP has already been contacted.

Royal Berkshire ffi NHS Foundation Trust lf thc coronsr has any queriee regarding the Trust's r€$ponss plcaae contac n Cc: The Chlef Coronsr