Dear Mr Potter,

I would like to start by expressing my sincere condolences to the family and friends of Mr Michael Crane. On behalf of the Commissioner of Police of the Metropolis, I write to provide our response to the matters of concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths, dated 25th October 2024, following the inquest into the death of Mr Michael Crane. The Coroner’s “Matter of Concern” “The MPS constable who gave evidence at the inquest, told me that:
• if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;
• the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and
• there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such.”

MPS Response: Training and Guidance in Mental Health

The MPS recognises that staff will come into contact with people in crisis for a variety of reasons, including mental health. The MPS runs a scenario based approach to Public and Personal Safety Training (PPST), focusing on different interactions an officer is likely to face in the course of their day to day duties. It includes steps that can be taken to manage interactions as effectively as possible. This training is mandatory for all operational police officers. All new recruits receive eight days of training and all police officers receive two days refresher training each year. Officers are directed to attend training centrally. Compliance is monitored, and attendance recorded through the corporate Learning Management System (LMS). This is an industry recognised computer-based system which holds individual training records for each officer in the MPS. In the event of an officer not attending training, this will be flagged to a supervisor and they will be directed to attend training. Prior to the LMS system going live in 2022, officers were directed by e-mail and when they completed their training, an alert was sent to HR for records to be updated on the central HR system known as the Police Standard Operating Platform (PSOP).

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The MPS provides all police constables with a mental health input during their foundation training, albeit the content varies depending on the date of joining, and will reflect the current policies and legislation at the time the training was designed.

The following principles are woven into lessons and scenarios, and this training is delivered to all new recruits irrespective of which pathway they enter the MPS:

Tactical communication This lesson is part of the recruit syllabus.  Potential barriers to communication, including mental ill health, are contained within it.  The Trainer Resource Pack comprises the following text: “Mental Ill Health: Officers are not expected to diagnose mental ill health in individuals that they come into contact with. Officers may however become aware, by a variety of means, that the person they are dealing with is believed to be experiencing mental distress or ill health.” Safety in mind
• A video is presented which has been created in conjunction with the London Ambulance Service and South London and Maudsley Hospital. It is aimed at, not only police officers, but others who may find themselves dealing with people in a mental health crisis. A discussion takes place regarding this input. It was created to coincide with the introduction of the Vulnerability Assessment Framework (VAF) following a report by Lord Adebowale.
• The VAF highlights how people may be vulnerable, for various reasons (not limited to mental health), and provides a list of indicators for officers to look out for when assessing vulnerability. This includes: Appearance, Behaviour, Communication (how are they communicating), Danger (to self or others), Environment (ABCDE assessment).
• It also includes the CARES mnemonic, which is how officers should approach vulnerable people (“Contain rather than restrain, Approach within view of the person, Reduce distractions, Explain what you are doing, Slow down your actions), and the role of the safety officer.
• The focus of the lesson is in dealing safely with people who appear to be experiencing a mental ill-health crisis and the subsequent handover to medical professionals.

Vulnerable person scenario
• The Scenario Based Training (SBT) annual PPST refresher training introduced in April 2024 includes a “vulnerable person” scenario. This focusses on dealing appropriately with a person in crisis (whatever the cause) and specifically includes CAMERAS (C: Contain the person, and avoid or restraint if possible, A: Continuously update the ambulance, M: Monitor the person's vital signs, E: Explain what you are doing to the person and their family, and use friends and family to help reassure them), CARES and the VAF in the associated “time on task” activities.
• The SBT approach, including the vulnerable person scenario, are due to be introduced to recruit PPST in 2025.

In early 2019, the MPS reviewed the mental health training that was delivered to officers and developed a bespoke one-day training package. The content was based on the College of Policing Authorised Professional Practice (APP), the London Crisis Care Pathway and the MPS Mental Health Toolkit. It incorporated relevant legislation (including the Mental Health Act 1983) and the voice of the service user, lessons learnt; and tested learning through a series of animated scenarios. It encouraged officers to implement their learning as well as seeking to highlight the perspectives of service users and mental health professionals. This training was concluded in April 2020 and has been delivered to 10,300 officers.

The College of Policing have developed APP which can be accessed online by all police officers. It is the official and most up to date source of policing practice. It covers a range of policing activities including an APP for mental health. It covers: strategic considerations; mental vulnerability and illnesses; mental health and detention (including Police Powers under Section 136 of the Mental Health Act 1983); mental capacity; mentally ill patients who are absent without leave from recognised care; safe and welfare checks and crime and criminal justice.

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The MPS had a Mental Health Toolkit up to July 2024. This was a living document containing guidance for officers on how to deal with all aspects of people who are mentally unwell or have mental illness. This has now been superseded by the Mental Health Share Point page which provides guidance and is also interactive. It contains sections on all topics of policing and mental health and has links to the associated legislation.

Use of Powers under section 136 of the Mental Health Act 1983

Section 136 of the Mental Health Act 1983 (s136 MHA) is the most commonly used piece of legislation by officers at mental health incidents.

It is a preserved power of arrest that allows for an officer to detain someone that they believe to have a mental disorder and to be in immediate need of care or control and to remove them to a place of safety.

The power to remove a person requires three conditions to be fulfilled before police act:

1. The person must appear to the officer to be suffering from mental disorder.
2. They must appear to the officer to be in immediate need of care and control.
3. The officer must think that it is necessary to remove the person in their own interests or for the protection of others.

The police officer is not expected to make a diagnosis of someone’s mental state

As previously mentioned, the training is very clear on what the expectations are of police officers when dealing with an individual suffering mental ill health. The s136 MHA power provides officers, who believe in good faith that someone is mentally ill and requires immediate care or control - to remove them to a place of safety where they can be examined by a registered medical practitioners and be interviewed by an Approved Mental Health Professional (AMHP), who can make any necessary arrangements for the individual’s treatment/care.

The officers dealing with Mr Crane acknowledged that Mr Crane had been at hospital for his mental health earlier that day, that he was inappropriately dressed for the weather conditions and that he was ‘hearing voices’. However, they formed the view that whilst Mr Crane did appear to be suffering from some kind of mental disorder (hearing voices), he was not in immediate need of care and control, and they did not deem it necessary to remove him to a place a safety. The conditions of use for s136 MHA therefore were not made out. The fact that officers did not invoke their powers under s136 MHA does not mean there was inaction on their part.

The officer that provided evidence at the inquest indicated that he understood his powers very well in accordance with the law and treated Mr Crane with empathy and care.

Missing Persons Guidance

The College of Policing/APP 2017 definition of a missing person is:

“Anyone whose whereabouts cannot be established will be considered as missing until located and their wellbeing or otherwise confirmed.”

Under this definition, the circumstances of an individual’s whereabouts simply being ‘unknown’ could result in the expectation that police are responsible for locating them, regardless of the circumstances. This is impractical, with unnecessary deployment being potentially damaging to the individual (e.g. breach of privacy), or by limiting the overall capability of police to respond effectively to missing persons (e.g. due to high levels of unnecessary and preventable demand).

To manage this, when an individual is reported missing, we must first consider whether there was any reasonable expectation or necessity for police to be informed at all. Mr Crane was not reported missing to Police and his whereabouts were largely known during his time away from the care home.

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The officers were aware that Mr Crane had been at the hospital that morning. They also considered that he was dressed inappropriately for the weather conditions and noted that he was referring to ‘hearing voices’. However, they formed the view that he was generally coherent and there were no grounds to detain him under s136 MHA. One of the officers telephoned the care home, who advised that they had not reported Mr Crane missing but that they intended to do so in about 30 minutes’ time. The officers noted that Mr Crane was becoming more and more anxious to leave the police station and they allowed him to do so, as they had no policing powers to detain him.

Even in the event that Mr Crane had been reported missing, the officers options were extremely limited. They had already formed the view that he did not meet the criteria for s136 MHA to be used and as Mr Crane was an adult, there were no other policing powers available to them. The care home were informed where Mr Crane was and provided no further details to the officers as to any risk Mr Crane may have posed to himself/others or any further details about his mental health that could have raised the risk to him.

If there was heightened risk to Mr Crane, it was for the mental health professionals or care home to make this clear throughout the multiple touch-points across the agencies on 15th or 16th January and this includes the best opportunity of all when the officer called to inform the care home they were with Mr Crane at the Police Station. Please do not hesitate to contact me should you require any additional information or clarification regarding the contents of this response.

Dear Mr. Potter,

I refer to the prevention of future deaths report you issued following the conclusion of the inquest touching upon the death of Michael James Crane.

For ease of reference and clarity, we have used the topic headings provided in your report and responded accordingly:

• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours.

I have gathered the below chronology- 15th January- MC had spent the day in and out of island place, had taken his meds and appeared settled, he had made a request to the senior for her to contact his social worker as he had been without money for weeks. 15th January 19:00- MC was noted to be off unit at 19:00 by staff. 16th January – 05:54- MC presented himself at a police station who taken him to St Thomas Hospital after attending a police station in London claiming to be unwell. 16th January 08:30- the police in London called Island Place to advise that MC had gone to hospital and that the mental health team had been in touch with MC’s Leicester mental health team and were caring for his mental health routinely. At this point MC had been off unit 13.5 hours and was not reported missing because he was not missing, we knew he was at St Thomas’s hospital in London and therefore did not need to report him as a missing person. 16th January 11:55- MC was escorted by a member of the hospital staff for a cigarette however he left the hospital and was seen boarding a bus bound for Victoria station. 16th January 12:00- St Thomas hospital called Island Place and said MC had absconded from the hospital. 16th January 16:00- Senior at Island Place called St Thomas hospital to see if he had returned and he had not. 16th January 17:30- PC Cante from town croft police called to say they had approached MC in the street to do a welfare check on him and they asked if he was under any section, police said MC expressed he wasn’t ready to return to Island Place and they didn’t have any hold over him. Police gave Mc the homes number and said to present himself to the police station or the hospital when he is ready to go back to Island Place, police said he did not seem like a threat or a concern. The home had not reported him missing yet due to him only leaving hospital at 11:55, however they were going to report him missing shortly before this call due to him absconding from the hospital, they then made the decision not to as they had spoken to the police at 17:30 and again, he technically wasn’t a missing person. 16th January 18:00- after spending 30 minutes in the general vicinity of charing cross police station MC leaves the area and his whereabout are then unknown.

16th January 23:00- police from Charing cross call Island Place to see if MC had returned to Island Place 17th January- throughout the day- Island Place had been in touch with MC mental health team as MC was under a community treatment order and could be recalled back to hospital, MC responsible clinician agrees to recall MC back to hospital for treatment and issues the recall paperwork. The paperwork is received at Island Place at 17:00 17th January- 17:00- Island Place report MC missing to the police as it had been 23.5 hours since last hearing of his whereabouts and he had been recalled to hospital by his responsible clinician- incident number 465/17.01.24- reported to
- collar number 7903. 18th January 12:00- MPS marine police unit recover a dead body from the Thames which is identified as MC. 18th January 19:00- MPS called Island Place to inform they had found him deceased in the river Thames- reference number .

This suggests that Michael was reported as a missing person on the 17th January, after he had been missing for 23.5 hours, the rational around not reporting him missing prior to this time is that he wasn’t actually missing, we had been informed of his whereabouts and had been kept up to date on his location, there was no suggestion that Michael lacked capacity and therefore it was his right to come and go from our premises as he wished.

• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London.

There is a clear policy regarding what to do once they become aware of a missing resident, Michael had full capacity to travel wherever he wanted and therefore there was no action for the staff to take when they had contact from the police in London.

• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so.

On the 17th January, after Michael had been missing for 23.5 hours and the staff had not had contact from either home or any relevant professionals, Michael was reported as a missing person to Leicestershire police and there was the relevant paperwork completed by his responsible clinician in order to recall him to hospital for an inpatient stay, as part of his community treatment order conditions.

• details about any additional training or steps taken to reduce the risks were very vague.

Prime Life offer a comprehensive induction and training schedule which allow ongoing education and professional development, the training data at the time of the tragic incident were well within our internal KPI, additional steps to reduce risk were limited due to Michael having full capacity around his day to day living, it was his right to go to London and was his right not to stay at the service if he didn’t wish to, the staff supporting Michael at the time were not duty bound to extend this support into the community when Michael decided to leave Island place and head towards London.

• details of specific policies and procedures in place at the time were vague.

There are a full set of policies and procedures available to all staff, which have since undergone a full review.

• There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident.

At the time of their contact with Michael, he was not a missing person, the home had not reported Michael missing as they had contact with the hospital and the police regarding Michaels whereabouts and therefore didn’t see it necessary to report him as a missing person, it was only after a longer period of no contact that the home reported him missing, as it had been 23.5 hours and his responsible clinician had issued the relevant paperwork in order for Michael to be recalled to hospital under his community treatment order terms.

Conclusion-

As a provider we are committed to learning lessons from incidents such as the tragic one with Michael, since this incident we have reviewed our missing person policy and have provided additional training to the staff and management at Island Place in order to ensure that they have clear guidance on when and understanding in how quickly a person should be reported missing.

I would like to end this report, by sending my condolences to Michaels family and friends.