Anne Wilson
21 Jul 2015 · Coroner Sonia Hayes · London (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of shared welfare check policy
“In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time.”
2. inadequate welfare check guidance
“MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain: (a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised (b) an example of how to manage a request for a welfare check concerning the mental health of an individual (c) how to manage additional information received once a welfare check request had been closed. (d) The”
3. downgrading without full information
“The information provided by Miss [name redacted] G.P to the MPS was available in full with those making the decision to downgrade the request for a welfare check: (a) Miss [name redacted] had suffered a relapse of severe depression (b) had just been discharged from psychiatric hospital (c) the welfare concern was raised by the discharging Consultant [name redacted] and G.P (d) the G.P had specifically requested forced entry to Miss [name redacted] property”
4. failure to inform GP of downgrade
“property (4) The MPS call handler informed Miss [name redacted] G.P that the police would attend Miss [name redacted] flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek South London Area”
5. delayed contact with GP
“The MPS did not share the G.P's mobile telephone number with the LAS causing delay making further contact with the G.P”
6. unclear policy version
“It is unclear what version of the MPS Welfare Check policy in currently in force and a final version has not yet been shared with the LAS despite requests to do so”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time.”
Later report
“The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact.”
Closely relatedConfidence 0.90 · high
This report
“(b) an example of how to manage a request for a welfare check concerning the mental health of an individual”
Later report
“dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health”
Responses
2015-0293-Response-by-London-Ambulance-Service-NHS-Trust.pdf ↗· London Ambulance Service
Stated action · end of September 2015
“a Control Services Bulletin will be issued at the 15/89/2015 15:56 62077832889 LAS_LEGAL | PAGE 63/83 end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient being closed prior to assessment by a clinician.”