Joseph Martin
PFD Report
Historic (No Identified Response)
Ref: 2021-0389
Coroner's Concerns (AI summary)
Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.
View full coroner's concerns
Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived.
His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others.
The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further.
However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts.
Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given.
There were individual errors, and more significantly a system that does not seem to have provided a safety net.
His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others.
The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further.
However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts.
Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given.
There were individual errors, and more significantly a system that does not seem to have provided a safety net.
Sent To
- Police Service of Northern Ireland Belfast
Response Status
Linked responses
0 of 1
56-Day Deadline
11 Jan 2022
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 10 June 2021, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Joseph Martin aged 43 years. The investigation concluded at the end of the inquest earlier today. The determination made at inquest was as follows. Joseph Martin died from . The exact circumstances of him are unclear, but there is no evidence of any other person being involved, and he was suffering a psychotic relapse at the time. The medical cause of his death was:
Circumstances of the Death
Joseph Martin had approached Metropolitan Police Service (MPS) officers near Westminster Bridge on 3 June 2021. The considered his mental welfare and contacted the police force local to where he lived, the Police Service of Northern Ireland (PSNI).
However, the MPS were not given full details of the concerns about his mental health raised with the PSNI by his family, friends and mental health team, so the officers had no power to detain him under section 136 of the Mental Health Act. They walked him to the nearest hospital, but he did not enter it.
However, the MPS were not given full details of the concerns about his mental health raised with the PSNI by his family, friends and mental health team, so the officers had no power to detain him under section 136 of the Mental Health Act. They walked him to the nearest hospital, but he did not enter it.
Copies Sent To
, uncle of Joseph Martin
Dr , psychiatrist, St Luke’s Hospital, Armagh
, manager, Simon Community, Armagh
Constable , PSNI
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.