Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of mental health risk assessment training and timely referrals
The earlier warning
William Hafele · 24 Nov 2014 · Martin Fleming, Surrey
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
judiciary.uk/prevention-of-future-death-reports/william-hafele
What was promised
Stated action 1 · response to William Hafele (24 Nov 2014) · stated timescale: January 2015
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”
What recurred
- 18 Sept 2024 · Helen Kerr · Caroline Topping · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · William Hafele · 24 Nov 2014
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
Later · Helen Kerr · 18 Sept 2024
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
What happened next
No web check of the stated actions has been published for this chain.