Vaughan Whalley
16 Jun 2023 · Coroner Catherine McKenna · Manchester North
The coroner's concerns
1. lack of suicide risk assessment upon release
“No assessment of the risk of suicide or self-harm upon release took place during the Deceased's time in detention”
2. lack of clear communication to police about assessment
“lack of clear communication to the Police as to what, if any assessment had taken place”
3. inappropriate communication method
“The conversation between the Practitioner and the Deceased took place through an observation hatch in circumstances where no risk was posed to the Practitioner from being in the same room as the Deceased. This was not best practice”
4. misleading terminology about Liaison and Diversion service
“The terminology used by the Practitioner was misleading in that it suggested that there was no role for the Liaison and Diversion service because no unmet needs or vulnerabilities had been identified. The evidence was that the Deceased had declined consent for an assessment of unmet needs and vulnerabilities and therefore the notes should have made clear that an assessment of unmet needs and vulnerabilities had not taken place”
5. superficial review with no learning
“The 'review' undertaken by a Health & Justice Operational Manager of the West Mercia Health & Justice Service consisted of duplication of the Practitioners statement with no comment, observations or identification of areas of learning”
Responses
2023-0366-Response-from-Midlands-Partnership-University-NHS-Foundation-Trust.pdf ↗· Midlands Partnership NHS Foundation Trust
Stated action · 09/08/23
“As a result of the concerns raised we have undertaken a review of the risk assessment processes across our Health and Justice Services. Some inconsistencies in the standards were identified which we have addressed by the development of a Standard Operating Procedure for risk assessment to be applied across Health and Justice Services. The SOP incorporates standards for conducting and sharing risk assessments for people in Police custody. Included in the SOP is a requirement for risk related information”