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recurance

Sophie Cotton

27 May 2025 · Coroner Rebecca Sutton · Durham and Darlington

The coroner's concerns

  1. 1. police refusal to attend

    “During the 16:44 call, by following the "Right Care, Right Person" procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life”
  2. 2. lack of police entry to locked premises

    “During the 16:44 call the "Right Care, Right Person" advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises”
  3. 3. no police attendance despite multiple concerns

    “During the 16:57 call there was no decision for police to attend, even though this was the third caller (and second professional caller) that had expressed serious concerns about the Deceased”
  4. 4. delay due to supervisor review

    “Although there is a procedure in place to have a negative "Right Care, Right Person" decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time-sensitive”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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