Karen Bingham
PFD Report
All Responded
Ref: 2020-0081
All 2 responses received
· Deadline: 25 May 2020
Response Status
Responses
2 of 2
56-Day Deadline
25 May 2020
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The evidence showed that:
1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times.
1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times.
Responses
Response received
View full response
Dear Madam
Karen Bingham deceased
I write in response to the Regulation 28 Prevention of Future Deaths Report that you issued in this case on 30 March 2020. I was very sorry to hear of Ms Bingham’s passing and I would like to pass my personal condolences to Ms Bingham’s family.
I am not able to respond to the first matter of concern raised in your report as this concerns Surrey Police alone. I therefore confine my response to the second matter of concern, namely:
“Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times”.
I would like to break your concern down into two areas:
1. SECAmb’s dispatch staff’s knowledge of police dispatch procedures
I understand that evidence was given to the inquest by two of my senior managers, and as to how SECAmb’s Emergency Operations Centre (“EOC”) functions so I do not intend to repeat that here. From that evidence, the Court is aware that a national triage system called NHS Pathways (“NHSP”) is used in our EOC to triage and categorise calls. NHSP arrives at a “disposition” – a call categorisation. Our Resource Dispatcher will see the incident immediately when the area of the incident becomes apparent and can assign a resource either immediately for a Category One (“C1”) call or after or during triage for other categories. This visibility allows the dispatcher to start planning a suitable resource to send to the patient during triage. The dispatcher will assign an ambulance resource when an appropriate vehicle becomes available in a reasonable vicinity of the incident. Resources are primarily assigned firstly according to urgency (C1 calls first, then category 2 etc) and secondly, within a category, on the length of time the call has South East Coast Ambulance Service NHS Foundation Trust Nexus House Gatwick Road
Crawley RH10 9BG
0300 123 0999
Chairman: Sir Peter Dixon Acting Chief Executive: Geraint Davies been waiting (the oldest C2 call will be assigned a resource before the second oldest etc). There are limited circumstances in which a call can be elevated to a higher priority than its place in the queue of outstanding calls. Dispatchers are supported by nurse and paramedic Clinical Supervisors, coordinated by a Clinical Safety Navigator, who are assigned to oversee ‘Clinical Prioritisation’ of all incidents awaiting resource allocation. Clinical Prioritisation includes undertaking clinical reviews of individual incidents, undertaking welfare checks, calling back cases for enhanced triage, upgrading/downgrading and prioritising individual cases within their existing categorisation. Furthermore, dispatchers have a route of escalation through a Dispatch Team Leader (DTL) and Clinical Supervisor to highlight any individual incidents where they have reason for concern.
Whether another emergency service is attending an incident and in what timeframe are not factors that would normally influence a dispatcher’s decision making. There are a very limited number of scenarios in which knowledge of the type and number of co-responders from other services being assigned may be of use, for example:
• If multiple police resources were attending a patient experiencing a mental health illness and were needing to restrain them, we might consider Acute Behavioural Disturbance and think about sending a Critical Care Paramedic.
• An incident involving multiple fire appliances would be a consideration for Hazardous Area Response Team allocation.
Our dispatchers are not specifically trained in police triaging or dispatching processes because such knowledge would so rarely factor into their dispatching decisions, which are based on clinical need.
As mentioned above, calls awaiting assignment of an ambulance resource are under constant review by a clinician, who does have the ability to alter the categorisation or priority of a call. The decisions of the clinician are made on clinical grounds; factors such as history, environment, load on our system are also taken into account. Knowledge of estimated arrival times of other emergency services would not influence these clinical decisions in the vast majority of cases.
Where there is concern between agencies, the issue can be raised at an operational or tactical management level where the principles of JESIP will be applied. Put simply, the Police Operational Commander can, and does, talk to the EOC Manager or Clinician Supervisor to discuss the incident.
In light of the above, I consider that the knowledge of my EOC staff of police dispatching processes is sufficient at present to enable them to carry out their functions safely and appropriately.
2. Police dispatch staff’s knowledge of SECAmb’s dispatch procedures
gave evidence to the inquest of the actions taken by SECAmb to ensure that our police colleagues are aware of our call categorisations and response targets. At the time the Ambulance Response Programme was rolled out in SECAmb (on 22 November 2017) a comprehensive document was prepared for our partner organisations and distributed to them. This includes the three police forces
Chairman: Sir Peter Dixon Acting Chief Executive: Geraint Davies with whom we principally work: Surrey, Sussex and Kent. We created and disseminated a further document for our partner agencies explaining our Surge Management Plan, including information on how we triage/prioritise calls, ARP response targets, SMP triggers and our actions. We also have in place a system for notifying Police Force Control Rooms by email when we reach the levels of our Surge Management Plan whereby there is a substantial risk that we will struggle to reach our target response times.
SECAmb rely on our police partners to disseminate internally the information that we provide. It is for each force to ensure that all relevant materials are cascaded to all those who need to know of their contents.
Notwithstanding the efforts we have previously made to ensure our police colleagues are aware of our processes, we have considered, in light of this case, whether we could go further. and the EOC Operating Unit Manager responsible for dispatch are in the early stages of a review of our Surge Management Plan. We consider that it would be constructive to involve all three police forces in our area as part of that review to discuss possible joint actions that could be taken when certain levels of stress on our system are reached. There are many options that we consider worth joint discussion, some of which could lead to closer working of our respective control rooms. will work with our Blue Light Collaboration Manager to liaise with our police colleagues to explore opportunities for closer collaborative working. Whilst I do not have a firm timescale for this review, particularly in current circumstances, I would very much hope that it will be concluded and implemented before the end of this year.
If I can assist you further in relation to any of the above, please do not hesitate to contact me.
Karen Bingham deceased
I write in response to the Regulation 28 Prevention of Future Deaths Report that you issued in this case on 30 March 2020. I was very sorry to hear of Ms Bingham’s passing and I would like to pass my personal condolences to Ms Bingham’s family.
I am not able to respond to the first matter of concern raised in your report as this concerns Surrey Police alone. I therefore confine my response to the second matter of concern, namely:
“Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times”.
I would like to break your concern down into two areas:
1. SECAmb’s dispatch staff’s knowledge of police dispatch procedures
I understand that evidence was given to the inquest by two of my senior managers, and as to how SECAmb’s Emergency Operations Centre (“EOC”) functions so I do not intend to repeat that here. From that evidence, the Court is aware that a national triage system called NHS Pathways (“NHSP”) is used in our EOC to triage and categorise calls. NHSP arrives at a “disposition” – a call categorisation. Our Resource Dispatcher will see the incident immediately when the area of the incident becomes apparent and can assign a resource either immediately for a Category One (“C1”) call or after or during triage for other categories. This visibility allows the dispatcher to start planning a suitable resource to send to the patient during triage. The dispatcher will assign an ambulance resource when an appropriate vehicle becomes available in a reasonable vicinity of the incident. Resources are primarily assigned firstly according to urgency (C1 calls first, then category 2 etc) and secondly, within a category, on the length of time the call has South East Coast Ambulance Service NHS Foundation Trust Nexus House Gatwick Road
Crawley RH10 9BG
0300 123 0999
Chairman: Sir Peter Dixon Acting Chief Executive: Geraint Davies been waiting (the oldest C2 call will be assigned a resource before the second oldest etc). There are limited circumstances in which a call can be elevated to a higher priority than its place in the queue of outstanding calls. Dispatchers are supported by nurse and paramedic Clinical Supervisors, coordinated by a Clinical Safety Navigator, who are assigned to oversee ‘Clinical Prioritisation’ of all incidents awaiting resource allocation. Clinical Prioritisation includes undertaking clinical reviews of individual incidents, undertaking welfare checks, calling back cases for enhanced triage, upgrading/downgrading and prioritising individual cases within their existing categorisation. Furthermore, dispatchers have a route of escalation through a Dispatch Team Leader (DTL) and Clinical Supervisor to highlight any individual incidents where they have reason for concern.
Whether another emergency service is attending an incident and in what timeframe are not factors that would normally influence a dispatcher’s decision making. There are a very limited number of scenarios in which knowledge of the type and number of co-responders from other services being assigned may be of use, for example:
• If multiple police resources were attending a patient experiencing a mental health illness and were needing to restrain them, we might consider Acute Behavioural Disturbance and think about sending a Critical Care Paramedic.
• An incident involving multiple fire appliances would be a consideration for Hazardous Area Response Team allocation.
Our dispatchers are not specifically trained in police triaging or dispatching processes because such knowledge would so rarely factor into their dispatching decisions, which are based on clinical need.
As mentioned above, calls awaiting assignment of an ambulance resource are under constant review by a clinician, who does have the ability to alter the categorisation or priority of a call. The decisions of the clinician are made on clinical grounds; factors such as history, environment, load on our system are also taken into account. Knowledge of estimated arrival times of other emergency services would not influence these clinical decisions in the vast majority of cases.
Where there is concern between agencies, the issue can be raised at an operational or tactical management level where the principles of JESIP will be applied. Put simply, the Police Operational Commander can, and does, talk to the EOC Manager or Clinician Supervisor to discuss the incident.
In light of the above, I consider that the knowledge of my EOC staff of police dispatching processes is sufficient at present to enable them to carry out their functions safely and appropriately.
2. Police dispatch staff’s knowledge of SECAmb’s dispatch procedures
gave evidence to the inquest of the actions taken by SECAmb to ensure that our police colleagues are aware of our call categorisations and response targets. At the time the Ambulance Response Programme was rolled out in SECAmb (on 22 November 2017) a comprehensive document was prepared for our partner organisations and distributed to them. This includes the three police forces
Chairman: Sir Peter Dixon Acting Chief Executive: Geraint Davies with whom we principally work: Surrey, Sussex and Kent. We created and disseminated a further document for our partner agencies explaining our Surge Management Plan, including information on how we triage/prioritise calls, ARP response targets, SMP triggers and our actions. We also have in place a system for notifying Police Force Control Rooms by email when we reach the levels of our Surge Management Plan whereby there is a substantial risk that we will struggle to reach our target response times.
SECAmb rely on our police partners to disseminate internally the information that we provide. It is for each force to ensure that all relevant materials are cascaded to all those who need to know of their contents.
Notwithstanding the efforts we have previously made to ensure our police colleagues are aware of our processes, we have considered, in light of this case, whether we could go further. and the EOC Operating Unit Manager responsible for dispatch are in the early stages of a review of our Surge Management Plan. We consider that it would be constructive to involve all three police forces in our area as part of that review to discuss possible joint actions that could be taken when certain levels of stress on our system are reached. There are many options that we consider worth joint discussion, some of which could lead to closer working of our respective control rooms. will work with our Blue Light Collaboration Manager to liaise with our police colleagues to explore opportunities for closer collaborative working. Whilst I do not have a firm timescale for this review, particularly in current circumstances, I would very much hope that it will be concluded and implemented before the end of this year.
If I can assist you further in relation to any of the above, please do not hesitate to contact me.
Response received
View full response
Regulation 28: Report to Prevent Future Deaths – Karen Jane Bingham
Document details
Authorising Officer
Author T/Assistant Chief Constable
Completed: 12/5/2020 Distribution HM Assistant Coroner Caroline Topping
Executive Summary: This report has been written in response to actions outlined within section 5 of HM Assistant Coroner’s regulation 28 report following the investigation and inquest into the death touching Karen Jane Bingham.
HM Assistant Coroner’s request for response to key areas of concern as follows:
1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times.
Surrey Police response (In respect of the order in which the points appear above):
1. Guidance is currently available via an APP on all officers’ Mobile Data Terminals entitled “Mental Health Guide”. This will be updated to ensure the comprehensive section on signs and indicators of mental health conditions is at the top of the page and the first thing available for officers to refer to. This will be closely followed with contact details for further assistance and advice which includes out of hours service available for all officers when faced with a potential mental health situation. The guidance also includes initial engagement advice, flowcharts detailing process and advice for officers who are considering sectioning an individual.
The Force is also publishing further details in relation to the roll out of mental health first aiders via the Occupational Health Unit which will give a clear list of support available to officers to help them identify and deal with mental health issues both with their own staff and when dealing with the public. Line managers are also to be delivered training on recognising mental health conditions which they will cascade to their own teams.
The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day training session for all of their staff on common mental health conditions later in 2020 to help those dealing with the public over the telephone recognise signs and symptoms.
There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.
2. In the summer and autumn of 2018 (since Karen’s death) all staff from the Contact Centre and Force Control Room (resource dispatch) received training from South East Coast Ambulance (SECambs). This included input on NHS Pathways (as described during the inquest), Ambulance Response Programme (categories of response and associated time frames) and their Operational Business Plan Surge (which protects calls with the highest clinical need where there is excess demand).
To supplement the training a number of staff “exchanges” between Surrey Police and SECambs to gain a better understanding of the roles of their respective contact and dispatch functions.
A quarterly meeting is held between the senior managers of Surrey Police’s Force Control Room, and SECambs Emergency Operations Centre to discuss any matters which may impact respective services including any themes from incident reviews (albeit these meetings have been postponed during the current Covid-19 pandemic).
A new Decision Support Flowchart, to help police officers and Contact Centre staff identify the appropriate NHS Pathway when dealing with members of the public (e.g. 999, 111, GP etc), has been agreed across Surrey, Sussex and Kent with a planned implementation date of October 2020.
Document details
Authorising Officer
Author T/Assistant Chief Constable
Completed: 12/5/2020 Distribution HM Assistant Coroner Caroline Topping
Executive Summary: This report has been written in response to actions outlined within section 5 of HM Assistant Coroner’s regulation 28 report following the investigation and inquest into the death touching Karen Jane Bingham.
HM Assistant Coroner’s request for response to key areas of concern as follows:
1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times.
Surrey Police response (In respect of the order in which the points appear above):
1. Guidance is currently available via an APP on all officers’ Mobile Data Terminals entitled “Mental Health Guide”. This will be updated to ensure the comprehensive section on signs and indicators of mental health conditions is at the top of the page and the first thing available for officers to refer to. This will be closely followed with contact details for further assistance and advice which includes out of hours service available for all officers when faced with a potential mental health situation. The guidance also includes initial engagement advice, flowcharts detailing process and advice for officers who are considering sectioning an individual.
The Force is also publishing further details in relation to the roll out of mental health first aiders via the Occupational Health Unit which will give a clear list of support available to officers to help them identify and deal with mental health issues both with their own staff and when dealing with the public. Line managers are also to be delivered training on recognising mental health conditions which they will cascade to their own teams.
The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day training session for all of their staff on common mental health conditions later in 2020 to help those dealing with the public over the telephone recognise signs and symptoms.
There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.
2. In the summer and autumn of 2018 (since Karen’s death) all staff from the Contact Centre and Force Control Room (resource dispatch) received training from South East Coast Ambulance (SECambs). This included input on NHS Pathways (as described during the inquest), Ambulance Response Programme (categories of response and associated time frames) and their Operational Business Plan Surge (which protects calls with the highest clinical need where there is excess demand).
To supplement the training a number of staff “exchanges” between Surrey Police and SECambs to gain a better understanding of the roles of their respective contact and dispatch functions.
A quarterly meeting is held between the senior managers of Surrey Police’s Force Control Room, and SECambs Emergency Operations Centre to discuss any matters which may impact respective services including any themes from incident reviews (albeit these meetings have been postponed during the current Covid-19 pandemic).
A new Decision Support Flowchart, to help police officers and Contact Centre staff identify the appropriate NHS Pathway when dealing with members of the public (e.g. 999, 111, GP etc), has been agreed across Surrey, Sussex and Kent with a planned implementation date of October 2020.
Report Sections
Investigation and Inquest
The inquest was opened on the 28th November 2017 and resumed before a Coroner with jury on the 4th February 2020. It concluded on the 18th February 2020 and the jury returned a narrative conclusion as follows: Karen first came in to contact with the Mental Health Services on 13/10/2014, when referred to Waverley CMHRS after an overdose. In March 2015 she was diagnosed with Emotionally Unstable Personality Disorder. The personality disorder is characterised by a highly unpredictable, rapidly changing emotional state, suicidal ideation with risk of self harm. In Karen's case this was exacerbated by alcohol.
Karen's mental disorder was also exacerbated by being the defendant in harassment proceedings and by her perception of being let down by the Criminal Justice System. On occasion, contact with the Police and Criminal Justice System triggered self injurious behaviours.
Karen had made a perjury allegation, and the CIO Officer investigating this allegation was aware of the above triggers.
On 09/10/2017, Karen called police saying she was going to hang herself. Police officers attended her home within 20 minutes and cut her down from a noose. Karen had been drinking and going through her legal paperwork and was found standing on a bannister, with a noose around her neck. Karen spoke to the attending police constable about her legal investigations including the perjury allegation.
The attending police constable raised concerns that Karen was at high risk of suicide, especially if the on going legal investigations did not give her the result she had hoped for. The PC attempted to escalate this concern using a 39:24, an LOI marker, and an email addressed to the CID Detective Sergeant, the Detective Constable investigating the perjury allegation, and the Surrey Police Professional Standards Department.
The CIO Investigating Officer and Detective Sergeant did not follow Surrey Police Protocol which required them to involve partner organisations (SABP) when dealing with Karen. They did however decide that news about the perjury investigation should be conveyed in person.
On 18th November 2017, the CIO Investigating Officer accompanied by a colleague attended Karen's address, Farnham, having arranged for Karen's friend to also be present. Karen was informed that her perjury allegation was being filed due to lack of evidence. The officers left Karen with her friend. Both officers felt that Karen was ok and had taken the news better than expected. Karen's friend also felt she was ok and left her alone around 15.15.
During the afternoon of 18/11/17, after her friend left, Karen consumed some alcohol and sent an email at 16.05 to the CID Investigating officer discussing her legal case and thanking the officer for her investigation. It is unclear when this email was drafted. It was entitled 'Final Statement' and closed with the words 'none of it matters anymore. This is what she wanted'. Karen's intent in sending this email is unclear and it was not read by the officer until much later.
At 16.15, Karen called the police on 101 and told the switchboard that she had been trying to hang herself and had broken her hand. The police contact centre called her back and although Karen assured the call handler that she was ok and did not require assistance, the call handler felt that an emergency ambulance and police response was required.
At 17.43 the ambulance crew arrived and were let in to the property by Karen's friend who had just arrived. Karen's friend entered the house with the ambulance crew and Karen was found hanging from the loft hatch. Her knees were bent with her feet trailing on the floor behind her.
The paramedics attempted to resuscitate Karen, however she was asystolic, cyanosed and could not be revived. The Critical Care Paramedic called ROLE (Recognition of Life Extinct) at 17.59 on 18th November 2017. Matters the jury finds are probably causative: In respect of the safeguarding plan put in place when telling Karen about the outcome of the perjury investigation on 18th November 2017:
1.Sufficient information was not obtained to inform safeguarding plan.
2.There was a failure to invite SABP to contribute to the plan.
3. There was a failure to put Karen's lay supporter on notice of the purpose of the visit on 18th November 2017, the concerns about Karen's reaction, and to discuss any role that person was expected to play in the safeguarding plan.
4. There was a failure to put in place an adequate multi-agency safeguarding plan.
Matters the jury finds are possibly causative, not found established on the balance of probabilities:
1. There was a lack of knowledge among police officers involved with Karen regarding how and when to add an update Location of Interest and warning markers on NICHE, PNC and ICAD.
2. The failure to add recent sufficient information to these markers possibly compromised the ability of the Police Contact Centre and Force Control Room to make an informed decision on 18/11/17.
3. It is possible that, had accurate up to date information been recorded, a Grade 1 police response might have been dispatched, despite Karen's assurances to the police call handler that she was now ok.
4. Had a Grade 1 police response been dispatched it could possibly have materially affected the outcome.
The jury concludes Karen met her death by accident. The cause of death was 1a Hanging
CIRCUMSTANCES OF THE DEATH These are fully set out in the narrative conclusion see above.
Karen's mental disorder was also exacerbated by being the defendant in harassment proceedings and by her perception of being let down by the Criminal Justice System. On occasion, contact with the Police and Criminal Justice System triggered self injurious behaviours.
Karen had made a perjury allegation, and the CIO Officer investigating this allegation was aware of the above triggers.
On 09/10/2017, Karen called police saying she was going to hang herself. Police officers attended her home within 20 minutes and cut her down from a noose. Karen had been drinking and going through her legal paperwork and was found standing on a bannister, with a noose around her neck. Karen spoke to the attending police constable about her legal investigations including the perjury allegation.
The attending police constable raised concerns that Karen was at high risk of suicide, especially if the on going legal investigations did not give her the result she had hoped for. The PC attempted to escalate this concern using a 39:24, an LOI marker, and an email addressed to the CID Detective Sergeant, the Detective Constable investigating the perjury allegation, and the Surrey Police Professional Standards Department.
The CIO Investigating Officer and Detective Sergeant did not follow Surrey Police Protocol which required them to involve partner organisations (SABP) when dealing with Karen. They did however decide that news about the perjury investigation should be conveyed in person.
On 18th November 2017, the CIO Investigating Officer accompanied by a colleague attended Karen's address, Farnham, having arranged for Karen's friend to also be present. Karen was informed that her perjury allegation was being filed due to lack of evidence. The officers left Karen with her friend. Both officers felt that Karen was ok and had taken the news better than expected. Karen's friend also felt she was ok and left her alone around 15.15.
During the afternoon of 18/11/17, after her friend left, Karen consumed some alcohol and sent an email at 16.05 to the CID Investigating officer discussing her legal case and thanking the officer for her investigation. It is unclear when this email was drafted. It was entitled 'Final Statement' and closed with the words 'none of it matters anymore. This is what she wanted'. Karen's intent in sending this email is unclear and it was not read by the officer until much later.
At 16.15, Karen called the police on 101 and told the switchboard that she had been trying to hang herself and had broken her hand. The police contact centre called her back and although Karen assured the call handler that she was ok and did not require assistance, the call handler felt that an emergency ambulance and police response was required.
At 17.43 the ambulance crew arrived and were let in to the property by Karen's friend who had just arrived. Karen's friend entered the house with the ambulance crew and Karen was found hanging from the loft hatch. Her knees were bent with her feet trailing on the floor behind her.
The paramedics attempted to resuscitate Karen, however she was asystolic, cyanosed and could not be revived. The Critical Care Paramedic called ROLE (Recognition of Life Extinct) at 17.59 on 18th November 2017. Matters the jury finds are probably causative: In respect of the safeguarding plan put in place when telling Karen about the outcome of the perjury investigation on 18th November 2017:
1.Sufficient information was not obtained to inform safeguarding plan.
2.There was a failure to invite SABP to contribute to the plan.
3. There was a failure to put Karen's lay supporter on notice of the purpose of the visit on 18th November 2017, the concerns about Karen's reaction, and to discuss any role that person was expected to play in the safeguarding plan.
4. There was a failure to put in place an adequate multi-agency safeguarding plan.
Matters the jury finds are possibly causative, not found established on the balance of probabilities:
1. There was a lack of knowledge among police officers involved with Karen regarding how and when to add an update Location of Interest and warning markers on NICHE, PNC and ICAD.
2. The failure to add recent sufficient information to these markers possibly compromised the ability of the Police Contact Centre and Force Control Room to make an informed decision on 18/11/17.
3. It is possible that, had accurate up to date information been recorded, a Grade 1 police response might have been dispatched, despite Karen's assurances to the police call handler that she was now ok.
4. Had a Grade 1 police response been dispatched it could possibly have materially affected the outcome.
The jury concludes Karen met her death by accident. The cause of death was 1a Hanging
CIRCUMSTANCES OF THE DEATH These are fully set out in the narrative conclusion see above.
Inquest Conclusion
Karen first came in to contact with the Mental Health Services on 13/10/2014, when referred to Waverley CMHRS after an overdose. In March 2015 she was diagnosed with Emotionally Unstable Personality Disorder. The personality disorder is characterised by a highly unpredictable, rapidly changing emotional state, suicidal ideation with risk of self harm. In Karen's case this was exacerbated by alcohol.
Karen's mental disorder was also exacerbated by being the defendant in harassment proceedings and by her perception of being let down by the Criminal Justice System. On occasion, contact with the Police and Criminal Justice System triggered self injurious behaviours.
Karen had made a perjury allegation, and the CIO Officer investigating this allegation was aware of the above triggers.
On 09/10/2017, Karen called police saying she was going to hang herself. Police officers attended her home within 20 minutes and cut her down from a noose. Karen had been drinking and going through her legal paperwork and was found standing on a bannister, with a noose around her neck. Karen spoke to the attending police constable about her legal investigations including the perjury allegation.
The attending police constable raised concerns that Karen was at high risk of suicide, especially if the on going legal investigations did not give her the result she had hoped for. The PC attempted to escalate this concern using a 39:24, an LOI marker, and an email addressed to the CID Detective Sergeant, the Detective Constable investigating the perjury allegation, and the Surrey Police Professional Standards Department.
The CIO Investigating Officer and Detective Sergeant did not follow Surrey Police Protocol which required them to involve partner organisations (SABP) when dealing with Karen. They did however decide that news about the perjury investigation should be conveyed in person.
On 18th November 2017, the CIO Investigating Officer accompanied by a colleague attended Karen's address, Farnham, having arranged for Karen's friend to also be present. Karen was informed that her perjury allegation was being filed due to lack of evidence. The officers left Karen with her friend. Both officers felt that Karen was ok and had taken the news better than expected. Karen's friend also felt she was ok and left her alone around 15.15.
During the afternoon of 18/11/17, after her friend left, Karen consumed some alcohol and sent an email at 16.05 to the CID Investigating officer discussing her legal case and thanking the officer for her investigation. It is unclear when this email was drafted. It was entitled 'Final Statement' and closed with the words 'none of it matters anymore. This is what she wanted'. Karen's intent in sending this email is unclear and it was not read by the officer until much later.
At 16.15, Karen called the police on 101 and told the switchboard that she had been trying to hang herself and had broken her hand. The police contact centre called her back and although Karen assured the call handler that she was ok and did not require assistance, the call handler felt that an emergency ambulance and police response was required.
At 17.43 the ambulance crew arrived and were let in to the property by Karen's friend who had just arrived. Karen's friend entered the house with the ambulance crew and Karen was found hanging from the loft hatch. Her knees were bent with her feet trailing on the floor behind her.
The paramedics attempted to resuscitate Karen, however she was asystolic, cyanosed and could not be revived. The Critical Care Paramedic called ROLE (Recognition of Life Extinct) at 17.59 on 18th November 2017. Matters the jury finds are probably causative: In respect of the safeguarding plan put in place when telling Karen about the outcome of the perjury investigation on 18th November 2017:
1.Sufficient information was not obtained to inform safeguarding plan.
2.There was a failure to invite SABP to contribute to the plan.
3. There was a failure to put Karen's lay supporter on notice of the purpose of the visit on 18th November 2017, the concerns about Karen's reaction, and to discuss any role that person was expected to play in the safeguarding plan.
4. There was a failure to put in place an adequate multi-agency safeguarding plan.
Matters the jury finds are possibly causative, not found established on the balance of probabilities:
1. There was a lack of knowledge among police officers involved with Karen regarding how and when to add an update Location of Interest and warning markers on NICHE, PNC and ICAD.
2. The failure to add recent sufficient information to these markers possibly compromised the ability of the Police Contact Centre and Force Control Room to make an informed decision on 18/11/17.
3. It is possible that, had accurate up to date information been recorded, a Grade 1 police response might have been dispatched, despite Karen's assurances to the police call handler that she was now ok.
4. Had a Grade 1 police response been dispatched it could possibly have materially affected the outcome.
The jury concludes Karen met her death by accident. The cause of death was 1a Hanging
CIRCUMSTANCES OF THE DEATH These are fully set out in the narrative conclusion see above.
Karen's mental disorder was also exacerbated by being the defendant in harassment proceedings and by her perception of being let down by the Criminal Justice System. On occasion, contact with the Police and Criminal Justice System triggered self injurious behaviours.
Karen had made a perjury allegation, and the CIO Officer investigating this allegation was aware of the above triggers.
On 09/10/2017, Karen called police saying she was going to hang herself. Police officers attended her home within 20 minutes and cut her down from a noose. Karen had been drinking and going through her legal paperwork and was found standing on a bannister, with a noose around her neck. Karen spoke to the attending police constable about her legal investigations including the perjury allegation.
The attending police constable raised concerns that Karen was at high risk of suicide, especially if the on going legal investigations did not give her the result she had hoped for. The PC attempted to escalate this concern using a 39:24, an LOI marker, and an email addressed to the CID Detective Sergeant, the Detective Constable investigating the perjury allegation, and the Surrey Police Professional Standards Department.
The CIO Investigating Officer and Detective Sergeant did not follow Surrey Police Protocol which required them to involve partner organisations (SABP) when dealing with Karen. They did however decide that news about the perjury investigation should be conveyed in person.
On 18th November 2017, the CIO Investigating Officer accompanied by a colleague attended Karen's address, Farnham, having arranged for Karen's friend to also be present. Karen was informed that her perjury allegation was being filed due to lack of evidence. The officers left Karen with her friend. Both officers felt that Karen was ok and had taken the news better than expected. Karen's friend also felt she was ok and left her alone around 15.15.
During the afternoon of 18/11/17, after her friend left, Karen consumed some alcohol and sent an email at 16.05 to the CID Investigating officer discussing her legal case and thanking the officer for her investigation. It is unclear when this email was drafted. It was entitled 'Final Statement' and closed with the words 'none of it matters anymore. This is what she wanted'. Karen's intent in sending this email is unclear and it was not read by the officer until much later.
At 16.15, Karen called the police on 101 and told the switchboard that she had been trying to hang herself and had broken her hand. The police contact centre called her back and although Karen assured the call handler that she was ok and did not require assistance, the call handler felt that an emergency ambulance and police response was required.
At 17.43 the ambulance crew arrived and were let in to the property by Karen's friend who had just arrived. Karen's friend entered the house with the ambulance crew and Karen was found hanging from the loft hatch. Her knees were bent with her feet trailing on the floor behind her.
The paramedics attempted to resuscitate Karen, however she was asystolic, cyanosed and could not be revived. The Critical Care Paramedic called ROLE (Recognition of Life Extinct) at 17.59 on 18th November 2017. Matters the jury finds are probably causative: In respect of the safeguarding plan put in place when telling Karen about the outcome of the perjury investigation on 18th November 2017:
1.Sufficient information was not obtained to inform safeguarding plan.
2.There was a failure to invite SABP to contribute to the plan.
3. There was a failure to put Karen's lay supporter on notice of the purpose of the visit on 18th November 2017, the concerns about Karen's reaction, and to discuss any role that person was expected to play in the safeguarding plan.
4. There was a failure to put in place an adequate multi-agency safeguarding plan.
Matters the jury finds are possibly causative, not found established on the balance of probabilities:
1. There was a lack of knowledge among police officers involved with Karen regarding how and when to add an update Location of Interest and warning markers on NICHE, PNC and ICAD.
2. The failure to add recent sufficient information to these markers possibly compromised the ability of the Police Contact Centre and Force Control Room to make an informed decision on 18/11/17.
3. It is possible that, had accurate up to date information been recorded, a Grade 1 police response might have been dispatched, despite Karen's assurances to the police call handler that she was now ok.
4. Had a Grade 1 police response been dispatched it could possibly have materially affected the outcome.
The jury concludes Karen met her death by accident. The cause of death was 1a Hanging
CIRCUMSTANCES OF THE DEATH These are fully set out in the narrative conclusion see above.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.