Dear Sir, Inquest touching the death of Samuel Thomas Linford Carroll (deceased) Response to Regulation 28 Report to Prevent Future Deaths dated 27 October 2016 Thank you for your report dated 27 October 2016, issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 in relation to the above inquest that was heard before you on 6 October 2016. I am aware that two statements were provided from both the Yorkshire Ambulance Service (YAS) Paramedic and Emergency Medical Technician who attended Mr Carroll on 6 May 2015. These were admitted in to evidence under Rule 23 of the Coroners and Justice Act and were read out at the inquest. YAS were not informed at any point that the inquest was being held, were not designated as an Interested Person for the purposes of the inquest and were not asked to attend to give evidence at the hearing. I would have welcomed the opportunity for YAS to respond to the concern you raise, either during the inquest or in the following 21 days between the conclusion of the inquest and the production of your report. Your concern was as follows: The ambulance service did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to hospital. As a consequence, no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following and earlier expression of suicidal ideation, Having reviewed the statements and documents from the attending YAS clinicians, Mr Carroll was reporting suicidal ideations, was a consenting adult and was taken to a hospital Emergency Department, as a place of salety. They further report that Mr Caroll was on his mobile phone throughout the journey and they believed that he was in contact with his brother. Given that this is all the information that was available to you from YAS, it is difficult to understand the evidential basis for your concern, and as this was not MINDFUL EMPLOYER V

explored further during the inquest with any representatives from YAS, it is unclear as to the detail of the actions and conversations which took place between the attending crew and Mr Carroll prior to his arrival at hospital. Having discussed this matter with a number of colleagues and managers from both the Clinical and Operations Directorates within the Trust, I can confirm that whilst not formalised in any written process, it is standard practice amongst clinicians as part of any welfare assessment of the patient to ask if there is any family member that can be contacted. If a decision is made to convey a patient such as Mr Carroll to a hospital or other appropriate place of care, there are commonly discussions had with the patient as to whether a family member can be contacted. The next of kin contact details are recorded on the Patient Care Record (PCR) whenever these can be obtained and this is then handed over to the receiving hospital or healthcare organisation on arrival, along with the duty of care to the patient. It would be expected that a longer term management plan is then put in place by the hospital for the patient prior to discharge which would include making contact with the patient’s relatives where appropriate. Given the acute nature of the ambulance function, the short period of time that is spent with patients, and the requirement under the duty of care to ensure the patient is conveyed to an appropriate facility and/or care handed over, I do not feel that under these circumstances that making contact with the family is the primary responsibility of YAS. If, however, on assessment, it is not appropriate to convey the patient, a referral to a more appropriate service (ie GP, mental health service etc) will always be made, and it is standard practice for the patient to be asked if there is any-one who they would like us to contact, whether that be a family member or other, and in these circumstances it would be expected as standard practice for this to be done by either the attending clinicians or another member of YAS personnel. I hope that my response provides you with reassurance that all appropriate mechanisms and processes are in place within YAS that relate to your concern, and that ensuring all patients receive the highest quality of care remains of utmost priority to the Trust. If I can be of any further assistance, or you require any further information in relation to the contents of this letter please do not hesitate to contact me.

Dear Mr Heath Re: Samuel Thomas Linford Carroll (deceased) Response under Regulation 29 Notice to Prevent Future Deaths - Samuel Carroll Thank you for affording me the opportunity to respond to your concerns raised within the above notice relating to the tragic death of Samuel Carroll. North Yorkshire Police is committed to improving the way we respond to people experiencing mental distress and recognises the importance of capitalising on every opportunity to prevent suicide. Indeed, the organisation has championed the aim of establishing a Suicide-Safer and Mental Health Friendly City and County, in partnership with the Directors of Public Health for York and North Yorkshire, which was launched on 28th October 2016. Your report contains three matters of concern; namely that:
1. “Police officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact that he was feeling suicidal or that he was being taken to the Hospital.”
2. [Refers to Yorkshire Ambulance Service]
3. “As a consequence no family orfriends were alerted to Mr Carroll being taken to or discharged from Hospitalfollowing an earlier expression of suicidal ideation.” As you have noted, officers did not make contact with friends or relatives before Mr Carroll was taken by ambulance to hospital. Given his apparent possession of mental capacity, his adulthood and the handoverto other professionals for his onward care, there has previously been no expectation that officers would make such intimations. The report produced by Bradford District Care Trust (BDCT), following their Serious Incident Investigation into Mr Carroll’s death, notes that in a meeting on July 2016, Mr Carroll’s family observed that they were unaware of his attendance at the hospital’s Emergency Department on the day of his death. It is clear from the evidence presented at inquest that Mr Carroll spoke to his partner, , whilst at hospital and again upon discharge. There is also mention that he may have spoken to his brother Steven whilst at hospital, but there is no witness testimony from him to corroborate Non-emergency CRIME5TOPPER5 Dave Jones MA cMgr FCMI I chief Constable Number Police Headquarters I Newby Wiske Hall I Northallerton North Yorkshire I DL7 9HA

‘I that. Indeed, following his discharge from hospital, Mr Carroll had extensive contact with family members and his GP, with evidence of forward-planning for the following day, before going on to take his own life. His reasons for confiding in his partner but not his family may never be known. Current Guidance To this juncture, existing guidance to our staff revolves around the determinations established in case of Webley vs. (1) The Commissioner of the Metropolis and (2) St. George’s Hospital Trust (2014), which focuses on the police “duty of care” to:
1. Take reasonable steps to ensure that a person does not come to physical harm while in police custody;
2. Take reasonable care to release the person into a safe environment; and
3. To provide relevant information to those into whose care a person was transferred. To that end, all existing training and policies pivots around these core determinations. Future Guidance and Training Since Mr Carroll’s death, North Yorkshire Police has commenced a pioneering Mental Health Awareness training programme for officers, which has been developed in collaboration with the College of Policing, University of York, Tees, Esk and Wear Valleys NI-IS Trust (TEWV) and people who have experienced significant mental health issues. This face-to-face training, which commenced on 18th May 2016 and was delivered by mental health professionals from TEWV to the first tranche of around 200 operational officers and staff, is to be subject of evaluation by means of randomised control trial. Once evaluated, it is anticipated that this will be rolled-out to all public-facing NYP staff. It is expected that the evaluation of the training programme will be completed by March 2017 and once approved by the College of Policing, it will be rolled-out across the remaining staff throughout 2017/2018. It is worthy of note that the training includes a video scenario revolving around a suicidal person in the hospital Emergency Department and the expectations upon our staff to take positive steps to secure their safety (in line with Webley above). C In light of your report, I will make sure that this training includes instruction to staff to make sure that steps are taken to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing. This must be balanced against considerations of whether that nominated person may potentially exacerbate the situation, given that feelings of suicidality often emanate from relationship / familial difficulties. The investigation by BDCT also made observation that NYP staff could have contacted the First Response Service operated by the Trust to accelerate the process of mental state assessment. Again, prior to receipt of your Regulation 28 Notice, the availability and functionality of the First Response Service was reiterated to staff in the Craven District. However, I will ensure that this valuable service is again communicated to our staff.

10th October 2016, the College of Policing launched Authorised Professional Practice (APP) in respect of mental health and suicidality. The document includes the salient advice: “Officers should avoid leaving a potentially suicidal individual alone based on their promise to visit their mental health worker or the hospital, and should seek to ensure that family members or significant others are on the scene and accept responsibilityfor help-seeking.” This APP has been made available to NYP staff and will form the basis of an NYP Mental Health and Suicidal People Policy, which is expected to be published in April 2017. Conclusions In conclusion, the following summarises the actions to be taken and the expected delivery times:
1. Mental Health Awareness training programme
- delivered to 200 front-line officer in May 2016 and to be delivered to the remaining staff throughout 2017/18;
2. Above training to include instruction to staff to attempt to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing;
3. To re-iterate to staff the availability and the role of First Response Service
— now;
4. North Yorkshire Police’s Mental Health and Suicidal People Policy to be amended to reflect the College of Policing’s Authorised Professional Practice (APP) in respect of mental health and suicidality
— by April 2017. I trust that this response complies with your requirements. However, please do not hesitate to contact me if you require any further information.