Tcherno Bari
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. high-risk mental health patient missing
“when a high-risk mental health patient is missing it requires effective and meaningful multi-agency co-ordination”
2. missing patient risk rating not provided
“BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy”
3. challenge process not communicated
“the RCRP 'challenge' process has been effectively communicated to BSMHFT. Context”
Linked reports
Earlier report
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing.”
This report
“I am not reassured BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy.”
Responses
2024-0296-appendix-to-response-BSMHFT.pdf ↗· Association of Police and Crime Commissioners
Stated action · July 2024
“The policy describes the actions to be taken when a patient is missing or AWOL”
2024-0296-Response-from-APCC.pdf ↗· Home Office
Stated action · April 2024
“the APCC has developed guidance for members on the Right Care, Right Person approach. The guidance, which was launched in April 2024, strongly encourages PCC oversight of the planning and delivery of the Right Care, Right Person approach to ensure vulnerable people receive the right support from the right services.”
2024-0296-Response-from-BSMHFT.pdf ↗· National Police Chiefs' Council
Stated action · 26 July 2024
“The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out 'why the risk is considered to be present'. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”
2024-0296-Response-from-College-of-Policing.pdf ↗· College of Policing
2024-0296-Response-from-DHSC.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action
“I will respond on these points in particular”
2024-0296-Response-from-NHS-England.pdf ↗· NHS England
2024-0296-Response-from-NPCC.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
2024-0296-Response-from-the-Home-Office-1.pdf ↗· Home Office
2024-0296-Response-from-West-Midlands-Police.pdf ↗· West Midlands Police