SAR Thomas

Learning from the circumstances around the death of Thomas Orchard

1. Introduction

1.1 This Safeguarding Adults Review (SAR) is commissioned by the Torbay and Devon Safeguarding Adults Partnership (TDSAP) in response to the circumstances surrounding the death of Thomas Orchard on 10 October 2012.

Thomas was arrested and detained by Devon and Cornwall Police on 3 October 2012. The cause of his death was severe hypoxic – ischaemic brain damage, forensic reports (as stated in the IPCC investigation report 2012/016815) state that the underlying causes were an:

‘episode of asphyxia, effectively suffocation and cardio-respiratory arrest’ following a violent struggle, a period of physical restraint, a prolonged period in a prone position across the edge of the mattress in his cell and the use of an Emergency Response Belt around his face (IPCC Report 2012/016815).

Clozapine, or the recent cessation of Clozapine, was not thought to have played a part in his death.

Thomas had experienced a rapid decline in his mental health in the five days before his arrest. Mental health services and his support provider were aware of this decline and efforts were made to support him and attempt to address the underlying cause of his mental health crisis in the days before his arrest.

On the day of his arrest a team had arrived at his accommodation to assess him under the Mental Health Act 1983, attempts to treat his illness at home were recognised as unsuccessful.         

1.2 Pen picture: Thomas was 32 years old at the time of his death. He was a white UK heterosexual man. He lived in supported accommodation and was regularly seen by mental health practitioners as part of Care Programme Approach (CPA) support.

Thomas had enjoyed stable mental health for the previous three years; he was rebuilding his life and had a part time job as caretaker at a local church.

Thomas was a Christian and attended church every day. He played a role during church services and was part of the ministry team.

During this time he was coping well, and his family felt more confident and optimistic about Thomas’s situation than they had ever been. It was clear he was loved at the church, they are reported to have been like a second family to him.

1.3 The Safeguarding Adults Review (SAR): This review is conducted in accordance with section 44 of the Care Act 2014 and the Torbay and Devon Safeguarding Adults Partnership (TDSAP) Procedures.

Section 44 (i-v) of the Care Act 2014 stipulates that a Safeguarding Adults Board (SAB) must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if:

(a) there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and (b) condition 1 or 2 is met.

Condition 1 is met if – (a) the adult has died, and (b) the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

Condition 2 is met if (a) the adult is still alive, and (b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.

Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to – (a) identifying the lessons to be learnt from the adult’s case, and (b) applying those lessons to future cases.

1.4 The decision to commission a SAR: Between the initial referral for a Review and commissioning of the lead reviewer for this SAR there was a period of seven years (2013-2020).    

Thomas’s case was referred as a potential serious case review (SCR) to the Devon Safeguarding Adults Board on 20 March 2013 by Devon and Cornwall Police on the grounds that Thomas was a vulnerable adult, abuse or neglect may have played a part in his death and that it would be in the public interest to hold a review.

At the time of this referral the circumstances of Thomas’s death were subject to an Independent Police Complaints Commission (IPCC) (since January 2018 the ‘Independent Office for Police Conduct’) investigation and because of this no further information from the police could be disclosed.

This may have informed the SAB Chair’s decision not to commission an SCR at this stage, but to wait until the IPCC investigation was concluded and the police were able to release information.

There is no evidence that the organisations involved at that time were advised to secure records relating to Thomas in the light of a potential SCR at a later date.

On 22 January 2014, the IPCC made an SCR referral to the Devon Safeguarding Adults Board. The grounds for this referral were that the IPCC remit did not cover ‘other public services’ and that an SCR would be in the public interest in terms of comprehensively reviewing the way that organisations interacted with Thomas in the period leading up to his death. It was hoped that this learning would inform multi agency practice.

The SAB initially agreed in February 2014 that Thomas’s case should be part of a thematic review about mental health crisis care. Information was gathered from the Devon Partnership Trust’s (DPT) root cause analysis and from Thomas’s family. No information was gathered from the support provider, Caraston House Ltd, who were left unaware that an SCR had been initiated.

In December 2014, the SAB Chair decided to withdraw Thomas’s case from the thematic review in the light of the intended criminal prosecution of three custody staff for manslaughter and to await until these matters were concluded before proceeding.

The Care Act 2014 came into force in April 2015. One of it’s provisions was to replace Serious Case Reviews with Safeguarding Adults Reviews, a learning process governed by statutory guidance.

In 2017, two Detention Officers and a Police Sergeant were found not guilty of manslaughter. The IPCC agreed with the SAB that a review, now a SAR, should be commissioned in July 2017. However, in April 2018, the Office of the Chief Constable of Devon and Cornwall police pleaded guilty in respect of the breach of section 3 of the Health and Safety at work Act 1974 on the basis that the breach did not contribute to the death of Thomas.

The Safeguarding Adults Review subgroup decided to wait until the conclusion of judicial processes connected with the death of Thomas. Sentence was passed on the Office of the Chief Constable in May 2019 following a Newton Hearing where the Judge concluded that he was not satisfied that the ERB was causative of Thomas’s death.

The SAR was commissioned in March 2020. The initiation of the SAR was delayed during the early stages of the COVID 19 pandemic in the UK. Terms of reference were developed in July 2020 and adopted in October 2020. A further short delay occurred in Spring 2021 as SAB partners were coping with pandemic related demands and staffing issues.  

The substantial delays in commissioning this SAR have had a number of consequences:

• Some of the organisations who were not asked to preserve records in 2013 when the SCR was referred have subsequently destroyed records as part of the cycle of record destruction. These organisations were not informed of the possibility of a Review.
• New electronic recording systems necessitated data migrations and organisations had access to some but not all records as not all information is uploaded onto new systems. 
• The national and local landscape in which Thomas died has changed. Since this time there have been national and local initiatives to improve the way that agencies work together when people are in crisis, in particular the 2014 Mental Health Crisis Care Concordat.
• Staff members who were involved in the original events have long left the organisations concerned so reducing the practitioner perspective in the SAR.
• Memories of the events and working practices of the time have been obscured by the passage of time and now well-established new working practices.

The delays in the commissioning of the SAR will be addressed in the Findings (section7) and Recommendations (section 9) below.

2. Terms of reference

2.1 The SAR focuses on learning about how organisations worked together to support Thomas in the time leading up to his mental health crisis and on the day of his arrest, and on what has changed in the intervening years.

The SAR will ascertain if relevant findings of the previous investigative processes have been acted upon, and what changes have been made in the way services work together since Thomas’s death.

Key overarching questions are – how would organisations and their frontline staff respond in 2021 if a person had a mental health crisis in a public area? Can the TDSAP be assured that agencies now work together to prevent, and intervene in, mental health crisis situations? 

2.2 The SAR will consider events from 1 October 2011 to 10 October 2012, the day that Thomas died.

Rationale: The timescale allowed for the potential to identify any opportunities pre-October 2012 to prevent the chain of events that led to Thomas’s mental health crisis.       

3. Methodology

3.1 The review had three parts: 

Part 1: Analysis of written evidence to identify themes for further exploration.

Evidence included relevant investigations that had already taken place, individual agency reviews submitted in 2020 and responses to questions asked of agencies by the current SAR lead reviewer.

Themes were developed with a SAR Panel of relevant organisation representatives who were not connected to Thomas’s case.

Part 2: How are the identified themes from the 2012 events being addressed in 2020?

Organisations were asked to submit a second written report considering how the central themes identified in Part 1 are being addressed in 2020-2021, including:

How are provided services supported to ensure the safety and wellbeing of a person experiencing a mental health crisis, and others in the same household?

How are existing risk assessments utilised and updated when a person experiences a relapse or mental health crisis? How is contingency planning utilised? Which agencies are alerted, how and in what circumstances? 

Interagency information sharing: Are the police and mental health services currently able to communicate potential risk to the person and public in real-time? What mechanisms and protocols support this? What impact did the crisis care concordant have on information sharing or communication between agencies in Devon?

Frontline police officers: How are officers trained and supported to a) defuse conflict or violence and b) recognise people who are experiencing mental health crises and assess or use the most proportionate approach to the situation? c) access support from mental health services?

Custody staff: How are custody staff trained to a) defuse conflict or violence and b) recognise people who are experiencing mental health crises and assess or use the most proportionate approach to the situation? What access do custody staff have to support from mental health services?

How have restraint practices changed since 2012? What systems are in place to promote the welfare of all persons subject to restraint or detention by Devon and Cornwall police?

How are families supported after similar incidents with a tragic outcome? How do we support each other?

Part 3: Learning event

After analysis of submissions on contemporary practice the SAR Panel convened a learning event where frontline staff and their managers considered Thomas’s situation as an anonymised case study in order to identify the opportunities in the present for intervention to prevent and to react to a person in crisis in a similar position.

The learning event helped to develop the SAR findings and recommendations for improvements in multi-agency working with people in crisis.

3.2 The following organisations participated in the SAR:

• Devon and Cornwall Police
• Devon Partnership NHS Trust
• Devon County Council
• Caraston Hall Support Ltd
• St Thomas’ Medical Group  
• Royal Devon and Exeter NHS Foundation Trust

3.3 Activities undertaken by the lead reviewer during the SAR have included consideration of documents from processes that took place within five years of Thomas’s death.  

Root Cause Analysis undertaken by Devon Partnership Trust, completed in December 2012. 

Partial Collation of evidence for an SCR (Thematic Review) completed in January 2015.

Report of the Independent Police Complaints Commission investigation – the date of completion is unknown, but the final report is after January 2016. 

The lead reviewer has also spoken with Inquest, a charity set up to provide expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians (https://www.inquest.org.uk/about-us). Inquest has been supporting Thomas’s family through the court cases associated with Thomas’s death and other processes, including this review. 

4. Family involvement

Thomas’s family met with the Lead Reviewer to review the terms of reference prior to the draft being submitted to the SAR core group. The family had given a statement to support the Thematic review of 2014/2015 and added a further question regarding family support to that statement. This question was considered in Parts 2 and 3 of the Review.

A copy of the SAR report was shared with Thomas’s family. The family will be invited to consider if they wish to make a statement to accompany the publication of the SAR.

5. Relevant history prior to the time in scope

5.1 In the years before his last mental health crisis Thomas had begun to rebuild his life with the support of his church, Caraston Hall support staff and consistent care coordinator from the DPT mental health service.

Thomas had become very much part of the life of the church he attended. He went to a gym regularly and had improved his physical health. Thomas felt ready to start driving lessons and had applied for a provisional driving licence.  This application was supported by his GP who noted that Thomas’s mood and thoughts had been stable for the last three years.

5.2 It had taken Thomas some years to get to this point. He was diagnosed with paranoid schizophrenia in April 2004. He had periods of being homeless.

From 2004 onward he was admitted to hospital on five occasions, relapsing after stopping his medication and/or taking illegal substances. These admissions to acute mental health inpatient units were characterised by auditory hallucinations, paranoid delusions and ideas of reference.

When mentally ill in the past he was reported to become aggressive and threatening to others, this was contrary to his usual temperament. Thomas did have a history of very minor criminal offences, related to shoplifted or possession of cannabis. His last convictions were in 2004 and related to breaching Community Rehabilitation and Drug Treatment orders.

Thomas is recorded as having assaulted a fellow resident in a residential unit in 2009, punching him in the face in retaliation for throwing milk over him during an argument. This was dealt with via restorative justice and no further offences occurred after this time. 

5.3 Thomas did well in a long-term residential placement and after a planned transition took up a tenancy at supported living accommodation in Exeter on 9 May 2011. The address was near to Thomas’s church.

Support to people living in the accommodation was provided by Caraston Hall, at that time services were funded by Devon County Council via Devon Partnership NHS Trust (DPT) on a block contracted arrangement. This meant that a fixed amount was paid to the provider each year to provide support hours into properties, rather than each individual service user having their own allocated individual hours of support. 

Although records are limited due to the length of time lapsed, it appears that Caraston Hall provided 31 hours of support on a shared and one to one basis to service users at the property across the working week.

The property contained five lettable rooms and it is believed there were five residents, including Thomas, in September 2012.

5.4 Thomas was subject to the Enhanced Care Programme Approach (CPA) which meant that his support in the community was monitored and reviewed by a care coordinator, who in Thomas’s case was a senior mental health practitioner.

Thomas’s care coordinator had known him since 2009 and they are described as having a good relationship. The care coordinator saw Thomas on a regular basis; visits were scheduled every three to four weeks to monitor his progress.

In addition, CPA reviews took place every six months, during which Thomas would be assessed by a psychiatrist and decisions made in respect of his medication. Thomas’s care plans and risk assessment were updated during these reviews.

In addition to support from his care coordinator Thomas attended a Clozapine (brand name Clozaril) outpatient clinic on a monthly basis. Clozapine is recommended by the National Institute for Clinical Excellence for treatment resistant schizophrenia (Psychosis and schizophrenia in adults. Quality standard [QS80] Published: 12 February 2015 at https://www.nice.org.uk/guidance/qs80/chapter/quality-statement-4-treatment-with-clozapine)

The drug is carefully managed and controlled; in Thomas’s case this monitoring was undertaken by the DPT Clozapine Patient Monitoring Service. Regular blood tests are needed to monitor white blood cells and to ensure that the patient’s white blood cell count is not low (agranulocytosis).

The prescription of Clozapine does carry a risk of agranulocytosis and supressed immunity. Clozapine can also affect the heart, most commonly during the initial ‘titration’ period.

Thomas attended the outpatient clinic for routine blood tests on 5 September 2012. The clinic manager still remembers Thomas and confirmed that he rarely missed a planned appointment, and on the few occasions he did not attend he made an alternative appointment. The clinic manager described Thomas as quiet, but friendly, pleasant and cooperative when attending clinic.

6. Key events and analysis

6.1: June 2012

Thomas had been taking Clozapine 150 mgs with a small dose of Amisulpride 50 mgs, since 2009. Under this regime he reported that the audial hallucinations he experienced were less troublesome, less intrusive and not derogatory.

Thomas’s medication was changed at his Care Programme Approach review on 6 June 2012. Thomas had asked for a medication review as he felt very sleepy during the day in addition to sleeping for 10-12 hours a night. He had also been concerned about weight gain and was trying to get healthier. 

Thomas was recorded as being aware of the need to take his medication and, despite not always being happy with the side effects, he knew he had to continue with it to remain well

The meeting agreed that ‘as he was doing well’ Thomas could be taken off Amisulpride with the Clozapine increased by 50 mgs to 200 mgs to compensate. The December 2012 Root Cause Analysis undertaken by DPT after Thomas’s death established that whilst Thomas wished to come off Amisulpride as he was concerned about weight gain, the drug likely to cause weight gain was Clozapine, the drug that Thomas continued to take. 

An overall support and development plan, which included a risk assessment, was completed with Caraston Hall staff on 12 July 2012 and uploaded onto Thomas’s notes kept by DPT.  

The risk assessment notes that:

• Thomas has no convictions for violence or aggression but does have a conviction for criminal damage. 
• He does have a history of assault or harm to others – but only when mentally unwell.
• He has carried weapons in the past but not used them.
• He has harmed others only when provoked or attacked in self-defence, but he could demonstrate impulsive behaviour which would be frightening to others.
• He has threatened to harm others in the past.
• He can demonstrate a high level of distress but is not suicidal.
• He can lack awareness of the health and safety of others.
• He was sectioned in 2004 and 2009, prior to his section in 2009 he expressed thoughts of violence to staff at xxxx House which caused concern. He reports a fight with two men he lived with in 2004.

Triggers for his behaviour are known:

• Breakdown in his mental health. Behaviour has resulted in sectioning under the MHA in the past.
• Increase in risk if under the influence of (illegal) drugs.

The risk mitigation or planning is the same for each of these risks:

Caraston support worker to monitor daily and ‘within two weekly’ support sessions – look for relapse indicators such as not taking medication and isolating from others.

Contact manager and care coordinator if behaviours as above or relapse indicators occur. Contact police if a criminal offence occurs. If impulsive and frightening others or verbally aggressive talk to him to calm him.

Thomas’s regular DPT care coordinator and Caraston Hall support worker worked well together, keeping in frequent telephone contact and sharing information well. Thomas was seen by his care coordinator again on 5 September 2012.

‘Visited Thomas at home. He reported everything was going really well.  His support worker said that Thomas was doing really well also. He reported his sleep was fine, he has not had any panic attacks for ages, he has lost weight and he is feeling really positive about work and the church etc.

We discussed the possibility that Thomas might move into an independent flat with Caraston Hall if they still have a vacancy. We all thought that this would be a good idea and although Thomas is slightly anxious about taking on too much he really wants his own flat and this particular one sounds ideal. Support worker to discuss with Caraston managers if it would be possible and I will see Thomas again in one month’s time.

Thomas appears to be a reformed character, not drinking, smoking or taking drugs etc. Might be moving out and getting his own flat. Doing really well. Lost a lot of weight, works out 3 times a week’.

Later on 5 September, Thomas attended his regular appointment at the Clozapine clinic. It was noted that he had lost 1.5 kilos in weight and that this would continue to be monitored in the clinic. Thomas was not experiencing any health side effects from taking Clozapine.

A blood test error meant that Thomas could not pick up the Clozapine supply that day. He returned the next day, 6 September, and picked up 56 tablets, a month’s supply. 

6.1.2 Analysis

The Caraston Hall support worker and DPT care coordinator knew Thomas well and were consistent figures in his life. Their professional relationship appears to have been purposeful, they met with Thomas, shared information and plans and made sure that Thomas’s progress was carefully supported.

The DPT Root Cause Analysis (RCA) of December 2012 concluded that there was no ‘root cause’ identified to the chain of events leading up to Thomas’s death. The RCA concludes that patients need to be fully involved in decisions about their medication and to decide how to use medication. 

The report recommendation was that:

‘Awareness needs to be raised amongst teams, including consultant psychiatrists, in relation to holding discussions which are more meaningful regarding medicines management with people who use services. Care plans in relation to this should be in place. Resources are available to support staff with this’ (DPT Root Cause Analysis pages 3 and 9).

Thomas appears to have been involved in discussions about his medication during the CPA review but was potentially given the wrong advice. It is unclear whether the potential risks of coming off the medication were discussed with Thomas or considered at the meeting.

Thomas continued to take Clozapine and is documented as fully aware of and in agreement with the need to take medication.  There is no evidence of an agreed medication support plan around the change in medication. This medication combination had been helpful to Thomas over the past three years and how the planned change would be monitored should have been recorded and agreed.

It was known at the time that Thomas experienced memory issues. It is not known that these ever impacted on his self-administration of medication. A medication support plan could have also covered such a contingency. 

The risk assessment of 12 July considers how Thomas’s behaviour has changed in the past when he became mentally unwell and what actions should be taken to monitor for signs of relapse or respond to indicators or changed behaviour. The risk mitigation planning does not consider:

How to prevent or address risk to Thomas when he is unwell.

How to prevent or address risks to others – people living in the same accommodation which is not staffed 24/7 and to the public.

Who to share information with in order to prevent harm to Thomas or to others.

It is suggested that the police are called if ‘a criminal offence occurs’ but no reference to the need to consider sharing information with police colleagues who may encounter Thomas in public when mentally unwell.

There is no reference to actions that might be considered should Thomas lack capacity to decide to take his medication or keep himself safe.

The Mental Capacity Act 2005 was implemented in 2007 and should have formed part of a consideration of actions that could be taken, such as who would assess Thomas’s capacity to make a decision about his own safety or whether to take his medication? If Thomas lacked capacity to make these decisions who would be consulted as a part of a best interest decision? Thomas could have informed a record of who to consult.     

It is uncertain that Thomas was part of a discussion about his views and wishes should his mental health deteriorate.

The 2008 Code of Practice on the Mental Health Act 1983 (Mental Health Code of Practice (2008) page 143) encouraged professionals to ascertain Patients ‘advance statement of wishes and feelings’ and to record these. This is perhaps not quite as strong as the 2015 Mental Health code of practice which puts participation as a principle at the heart of all mental health activities (Mental Health Code of Practice (2015) page 23).

Thomas appears to have been an insightful person who had experienced mental health crises in the past, his views and wishes about what should happen should his mental health deteriorate again and his mental capacity to make decisions diminish would have been valuable.        

There were no planned contingency measures regarding the provision of extra staffing in the accommodation to keep Thomas and others safe.  

6.1.3 What has changed since 2012?

DPT report that they now have a specific policy about ‘advanced statements and future support plans’ and that all patients who have the mental capacity to do so are encouraged to engage in completing a plan which includes their wishes should they lack mental capacity to make decisions about their treatment in the future (https://www.dpt.nhs.uk/search?q=C24+Policy). These advance statements (My future support plan) are part of the DPT care planning process.

Advance statements are added to the person’s clinical record with an alert regarding their existence. A recent DPT audit of people in hospital showed that 50% had a recent Advance Statement or My Future Support Plan in place.

DPT reports that they have an ongoing programme of work to ensure this percentage increases, especially in the light of future Mental Health legislation which may require more choice and autonomy for patients detained under the MHA 1983. 

In 2021, DPT has a range of policies on risk (Clinical Risk assessment and management policy (R04) 2019), the clinical risk assessment and management policy asks staff to use the best practice approaches recommended by the National Institute for Clinical Excellence, such as, use both historical and actuarial information but also factor in clinical judgement, use ‘dynamic’ approaches to keep risk assessments updated and utilise:

• the collaborative development of practical strategies, based on the risk formulation and aimed at minimising the risk of a negative event occurring and/or minimising the likely resultant harm.

Risk management plans should address the safety needs of the individual, those in contact with them and the wider public, as well as considering the potential longer-term risks and benefits implementation will present to all concerned.

Positive risk management builds upon a person’s strengths and resources and should emphasise and facilitate recovery as well as minimising the likelihood of harm occurring (Ibid page 7).

It is likely that risk assessment and management has developed in DPT since 2012 to focus not only on identifying risk but on working with the person to create contingency plans. The emphasis is on the person participating in developing practical strategies. This level of risk planning is not evident in the records from 2012.

6.2 September 28 – 29, 2012

6.2.1 Thomas saw his GP on the morning of 28 September. He was concerned that the medication change made earlier that month was causing him to have increased saliva in his mouth. The GP gave him a prescription for hyoscine hydrobromide (also known as ‘Kwells’ and used for travel sickness).    

At 3pm that afternoon, Thomas’s support worker from Caraston Hall telephoned the DPT duty desk. The support worker reported that Thomas was making little sense, he was hearing voices and was very anxious, he had not yet got dressed which was unusual for him. The support worker was unsure if Thomas had been taking his medication.

The support worker agreed to accompany Thomas to see his GP, the duty worker also made a referral to the DPT Crisis and Home Treatment team (CRHTT) and left a message for Thomas’s care coordinator. As this was late on a Friday, Thomas’s care coordinator was not available and would not be back at work until the following week.   

The CRHTT picked up the referral within fifteen minutes, noting that the support worker had reported a sudden deterioration in Thomas’s mental state, that Thomas had a diagnosis of schizophrenia and was prescribed Clozapine, which he self-managed. He had been doing very well but now appeared confused, was responding to voices and had not felt able to get out of bed today. CRHTT spoke to the support worker again at 4.30 pm, he said that Thomas is usually ”responsive and funny”. The support worker made an appointment at the GP surgery at 4.10 pm for a review but Thomas had refused to attend.

The support worker told CRHTT that Thomas:

• had not been taking his Clozapine consistently, he had 26 tablets remaining out of 56, a month’s supply
• had not been using illicit substances or alcohol and had abstained from both for a long time
• had recently had Amisulpride stopped which was taken alongside clozapine

Thomas agreed to see the CRHTT. It was noted that Thomas lived in a ‘satellite house’ belonging to Caraston Hall which was not staffed.

CRHTT did ask initial risk assessment questions, was the support worker concerned about any risk to self or others? The support worker said that Thomas had been ‘a little confrontational’ when pressed to see his GP.  

CRHTT saw Thomas in his accommodation at 5pm and spoke with him for an hour. Thomas was in bed and appeared a little dishevelled and tired. He was pleasant in manner and denied that his mood was low – his main worry was that he was unable to sleep. Thomas reported that he hadn’t eaten since yesterday, but that Caraston staff had delivered a meal earlier.

Thomas told CRHTT that his Amisulpride had stopped ”around six months ago” but he had not experienced any deterioration in his mental health since then. Thomas reported concordance with medication initially, but when gently challenged said that he might have missed taking a few.

Thomas’s thoughts appeared clear, ordered and rational. Thomas denied any auditory hallucinations currently and did not appear to the CRHTT to be responding to external stimuli.

CRHTT’s initial risk formulation summary was that Thomas’s mental health had deteriorated, that he had not been taking his medication, but this was not a deliberate omission. Thomas was known to have difficulty remembering.

He had missed around seven days of Clozapine. CRHTT do appear to be aware of the risk assessment on Thomas’s DPT records noting that: ‘Thomas has a history of aggression to others’ but noted ‘he denied any thoughts presently of wanting to harm other people. He was polite and warm in manner to us. He denied any thoughts of self-injury or suicidal ideation’.

CRHTT explained to Thomas that because he had not been taking his Clozapine consistently the dose would need ‘re-titration’ from 1 October. Re-titration involves building up the dosage of a drug slowly whilst any potential side effects are monitored.

Thomas would need to have his bloods taken, and if the results were okay, would need his blood pressure, temperature and pulse monitored twice daily for a week and then once daily for a week.

Thomas appeared to understand this and was willing to see CRHTT workers for this purpose, Thomas agreed to see CRHTT again the next day at 2pm. He was taken onto the CRHTT caseload ‘to monitor for psychotic breakthrough’.

The CRHTT plan was to re-titrate Clozapine in the community, initiating this element of the plan on Monday 1 October when Thomas’s bloods could be taken and monitoring begin. CRHTT discussed this plan with a senior support worker at Caraston Hall and left Thomas with the CRHTT telephone number.  

When CRHTT visited the next day, Saturday 29 September, at 2pm, Thomas did not answer the door. A support worker was present in the house and eventually the team were able to see Thomas.

Thomas asked whether he could get his Clozapine back, he had not slept. CRHTT explained the health risks again and agreed to return at 6pm with something to help him sleep.

Thomas answered the door immediately at 6pm, he was dressed and appeared possibly paranoid to the CRHTT staff although he very assertively denied any psychotic symptoms or paranoia. He did say that he felt anxious. He appeared uncomfortable and guarded.

Thomas was given Diazepam and Zopiclone to reduce his anxiety and help him sleep. The team planned to telephone him the next day ‘to review anxiety, sleep, mental state and risk and arrange a home visit. Thomas would appear to be deteriorating’.

6.2.2 Analysis

The support worker followed the guidance in the risk assessment of July 2012 by contacting the DPT duty desk when he became concerned about Thomas’s health and saw indicators of relapse. Unfortunately, this occurred on a Friday afternoon when staff who knew Thomas were not able to respond to him and when regular services were not available.

The CRHTT responded very quickly to the possibility of Thomas relapsing, picking up the referral in fifteen minutes and seeing Thomas within two hours. They continued to try to remain in touch with Thomas throughout the weekend.

The team worked well with Thomas’s support worker but there is no record of CRHTT establishing who else lived in the house and whether there was any risk to others in the accommodation or whether Caraston Hall senior managers were aware of what was happening so that they could take measures to support Thomas and others in the house.

There is no record of any review of his support arrangements or discussion regarding an increase in support hours for Thomas whilst he was becoming unwell. The initial response to Thomas’s situation was hampered by the absence of contingency planning within the July risk assessment.

CRHTT were aware of Thomas’s history and risk assessment. He was presenting as willing to re start his medication and was concerned about the deterioration in his mental health.

It is unfortunate that Clozapine cannot be given without a blood test and careful monitored re – titration. Thomas was facing at least two or three days without his medication.

The CRHTT appear to be following the Mental Health Code of Practice (2008 s4.4, which states:

‘Before it is decided that admission to hospital is necessary, consideration must be given to whether there are alternative means of providing the care and treatment which the patient requires. This includes consideration of whether there might be other effective forms of care or treatment which the patient would be willing to accept’

Thomas’s presentation and willingness to start his medication would support a decision at the time to try an alternative to admission to hospital by treating him in the community. However, his prior history, of relapse after stopping medication and of being very unwell as a result, should have also been factored into this decision.

6.2.3 What has changed since 2012?

Practice and policy in 2021 would have enabled a range of options to support Thomas’s treatment in the community.

The commissioning of support for people in Thomas’s position is now focused on what each person needs rather than how many hours needed per premises. This makes it easier to increase support during a time of crisis.

Reviews of support hours are carried out by social workers separate from the mental health teams and the DPT regional social work leads have budgetary authorisation. This enables an increase in funding for support hours for a person experiencing deteriorating mental health.

Thomas was in a ‘low support’ house and probably only had one visit a day. Today Thomas’s support hours could be reviewed and increased at the same time.

Services providing support to people who are relapsing report that they can speak with a mental health clinician out of hours by using the DPT First Response service (https://www.dpt.nhs.uk/our-services/first-response-service).

Patients are also able to speak with First Response if, like Thomas, they feel anxious and unable to sleep. The service operates 24/7 365 days a year. The Mooring is also open for face-to-face contact in Exeter from 6pm – midnight or 12pm to midnight at weekends providing out of hours support for people in crisis. Providers find these services very supportive.

DPT have Home Treatment teams with the aim of helping people resolve and manage crisis through assessment and treatment in the patient’s home environment. Like the CRHTT these operate through weekends and evenings and can make as many as 2-3 visits a day.

In 2021, an Approved Mental Health Professional (AMHP) might accompany the Home Treatment Team on visits and can provide an assessment of capacity and consider whether an assessment under the Mental Health Act is required at an earlier stage. 

Apart from a ‘home treatment team’ approach these options were not available to Thomas in 2012. At the beginning of his relapse these options may have been able to form a support network which would keep Thomas safe until he could access his medication again.

However once Thomas lost capacity to make decisions about his treatment it is doubtful these provisions would have been effective.  

6.2.4 How would practitioners in 2021 respond to a similar situation?

Experienced mental health practitioners in the 2021 workshop discussed the approach taken in 2012, to attempt to re-titrate Thomas’s medication in the community and not in hospital.

Given the known history, that Thomas had previously been very mentally ill once he stopped taking his medication, and that his behaviour indicated a risk history to himself and others once unwell, they would have considered a different approach.

Staff in 2021 were also aware of the issue of a ‘rebound psychosis’ from sudden withdrawal of Clozapine, a concern that appears well recognised in 2021 and acts as a ‘red flag’ in terms of likely progression of illness.

From 1997 there were documented reports in psychiatric literature about the rate of psychotic relapse in patients withdrawn from clozapine (Witharana, D., & Basu, A. (2011). Rebound psychosis following withdrawal of clozapine. The Psychiatrist, 35(4), 155-155. doi:10.1192/pb.35.4.155).

‘which was reported as five times higher than that for a traditional antipsychotic such as haloperidol or flupenthixol. Clozapine withdrawal psychosis has also been observed to be severe in symptomology and is in some cases associated with delirium’.     

2021 staff commented that the principle of the ‘least restrictive option’ was sometimes misunderstood, in order to preserve the person’s rights and prevent harm to them as well as others pre-emptive action may need to be taken.  2021 staff thought that Thomas was left in the community for too long, the risk was that he would lose capacity to make decisions about his medication and become very unwell.

As well as ensuring that Thomas’s risk assessment was updated and shared with Caraston Hall 2021 staff would also establish who else lived in the house with Thomas. If individuals were open to DPT their care coordinators would be advised of events and be able to offer support to other tenants.   

Caraston Hall staff note that there can be a difficult period between the decision that someone needs to be in hospital and a bed becoming available. A person might be visited every day by the Home Treatment team, but non-qualified support workers will be working with them for the majority of the time. 

There needs to be a focus on more robust management in the community in the time between a person needing detention and admission to hospital, ‘we need to think outside the box’ for the benefit of the person.

Caraston have learned to insist that DPT staff speak to a manager regarding the person’s presentation and risk assessment, a non-qualified support worker may know the person well but be unable to understand the individual’s relapse behaviour or establish relative risk given the composition of the household.

Weekend contingencies are the hardest to address and it is important to keep Caraston, or any other provider, ‘in the loop’ regarding concerns that a person is experiencing a relapse.  

Mental health care coordinators of 2021 talked about sharpening up planning after a person has relapsed, what is the plan for next time? What does the person want us to do next time? Care coordinators would involve other agencies in this discussion and record clear plans on the person’s record. 

6.3 30 September – 2 October 2012  

6.3.1 Attempts to contact Thomas by telephone on Sunday 30 September were unsuccessful. The team decided to visit him in person. Thomas was seen at 5.30 pm that evening. He said that he had not slept the previous night, he had taken Diazepam but had lost the Zoplicone. He was not overtly demonstrating the positive symptoms of schizophrenia and agreed to meet the team the next day.

CRHTT staff visited the next day, Monday 1 October, at 11 am, this time with a psychiatrist, but Thomas was out of the building. The psychiatrist was hoping to medically review Thomas and organise re-commencement on Clozapine.

On Thomas’s return he was taken to the bloods clinic and provided a blood sample.  After confirming the blood work results the team planned to see Thomas again the next day, 2 October, to review his needs again and to recommence Clozapine.    

On the morning of Tuesday 2 October, the psychiatrist discussed Thomas’s Clozapine re-titration with the DPT pharmacy. Given the blood results and the fact that Thomas was not Clozapine naïve re-titration could take place ‘rapidly’ over five days.

The psychiatrist visited Thomas in the company of his regular care coordinator and a member of the CRHTT that afternoon.  Thomas’s mental health appeared to have deteriorated further since the weekend and he had positive symptoms of schizophrenia including thoughts that were completely out of character for this usually gentle man.

‘Thomas appears unwell today. On meeting him today he tells me that he is the best he has ever been ‘since I was 3 years old’. He says that this is because he is off of his medication and he has lost weight….. Thomas clearly has many strange thoughts at present….He reports that he has recently received many strange messages through the television and from the SAS directly to his brain…. The thoughts that Thomas are having seem to relate to weapons being smuggled from north Africa to Iran – which is something that he says he has recently become aware of. He is not sure of the relevance to him but thinks that the weapons are important as they are a threat to the Americans’.

Thomas did also talk about feeling that other people, particularly men of Asian appearance,  were watching him in Exeter and that he was having thoughts of attacking anybody that was watching him. He also talked about thoughts that he was a vampire and that because of this he should stay indoors during the day.

Thomas also described having two ‘fist fights’ with drug dealers in the Exeter region over the past few days. No evidence of injury to Thomas could be seen and these accounts were not believed. Thomas said that he was unsure if he would restart his Clozapine medication this evening because he did not think he needed it. 

In terms of risk the psychiatrist recorded, erroneously, that Thomas had spent time in prison for attacking individuals. This is not true and did not form part of Thomas’s recorded June 2012 risk assessment held by DPT.

It was recorded that Thomas expressed thoughts of attacking ‘pakis’ if they looked at him. The notes record that Thomas ‘is guaranteeing that he will not leave the building – but this is because he is a vampire and he cannot. He has no specific plans to attack anybody at present’.

The assessment concluded that Thomas was experiencing an ‘acute psychotic episode after stopping his Clozapine medication. At present he is guaranteeing his safety today and will not leave the house however while he is unwell his risk towards himself and others is high’.

The Plan made on 2 October was:

1. Offer clozapine this evening as previously planned, in addition we will offer Amisulpride medication 200 mg BD.
2. Twice daily crisis team visits to support and administer medications.
3. If he is non-compliant with Amisulpride and Clozapine medications this evening we will discuss in the crisis team meeting tomorrow and consider a Mental Health Act assessment.

At 9pm that evening, CRHTT attempted to see Thomas but after knocking and ringing could get no answer. They returned three quarters of an hour later and managed to get the attention of another resident who let them in.

Thomas had been in the bathroom for two hours. After 30 minutes Thomas was persuaded to come out of the bathroom. He was fully dressed, wearing dark sunglasses and a thick winter jacket.

Thomas was reluctant to take the medication offered but did allow the team to complete physical health observations.

Thomas said he would only take his medication if it was placed on his bed. He picked up the Clozapine tablet but then threw it across the floor. ‘He then was asking lots of questions about the medication, what it is made of, and will it shut down his brain’. The Amisulpride was also left on the bed, Thomas did not take the tablet but broke it in half and rubbed half over his nails, his hair and over his eyelashes.

Thomas became ‘more hostile’ towards the end of the CRHTT visit and the team record that they felt it safer to leave. They concluded that:

‘It does not appear a sustainable option for crisis team to support medication concordance, due to the time likely to be involved in order for him to take the medication, and that we cannot guarantee that he is actually taking the medication, which could lead to further relapsing and increasing in risk to others’.

6.3.2 Analysis

Thomas was compliant in attending the bloods clinic on Monday 1 October. By the afternoon of 2 October his mental health had declined sharply.

Despite Thomas being very unwell and saying that he had thoughts of attacking people there are no records of the risk assessment being updated. There is no record of consideration of the safety of others in the unstaffed building or of risk to Caraston staff. 

Risk assessments were not updated regarding the safety of Thomas or the public when he left the building in such an ill state. CRHTT and the psychiatrist knew that Thomas had left the building and could indeed do so again, Thomas was so unwell his ‘guarantee’ that he would stay at home could not be relied upon.

There was no information sharing with other agencies who might encounter Thomas in public when unwell and be able to use the advice in his risk assessment to approach him if needed, such as, ‘talk to him to calm him’.

At the time, DPT lacked mechanisms to share information with the police in real time and do not appear to have considered the possibility that information sharing would be a useful step in preventing harm to Thomas.

In 2015, the DSAB thematic review on mental health crisis care (Devon Safeguarding Adults Board Vulnerable Adults Mental Health Crisis Care: Thematic Review (May 2015)) found that there was an information sharing protocol and a form (MH1) widely used by mental health and police staff to facilitate sharing information. Sometimes information given was not reliably logged against a person’s record. The review concluded that co-location of the type that now exists between these services facilitated better information exchange.            

There are also indications that Thomas had begun to lose mental capacity to make decisions about re-starting medication. At this point there was an opportunity to develop an alternative plan to reintroducing Thomas’s medication in the community. Thomas’s mental capacity to make a decision about his medication was not assessed and, should he lack capacity, a review of the existing plan from a best interest perspective undertaken.       

The team pressed ahead with attempts to get Thomas to start taking medication again on the evening of 2 October. Thomas appears to be no longer capacitated to make this decision. He was threatening to CRHTT staff who felt it safer to leave the building. There is no record of this being shared with Caraston Hall staff so that they could be aware of the increased risk and negotiate extra staff to support Thomas to stay in his room and to support other residents.

There was no contingency plan to keep Thomas safe whilst an urgent Mental Health Assessment could be arranged. Without a dynamic risk assessment Thomas was left in his room with only his guarantee that he would not leave, an unsafe arrangement given Thomas’s prior history and degree of illness.

6.3.3 What has changed since 2012?

There have been a number of changes in policy and practice since 2012 which may have impacted on Thomas’s situation. 

The Crisis Care Concordat 2014 (Mental Health Crisis Care Concordat Improving outcomes for people experiencing mental health crisis (February 2014))

The Concordat was a shared agreed statement, signed by senior representatives from the organisations most often involved in mental health crisis care including health, police, and local authorities.

The Concordat focused on what should happen when people in mental health crisis need help – in policy making and spending decisions, in anticipating and preventing mental health crises wherever possible, and in making sure effective emergency response systems operate in localities when a crisis does occur.

The driving rationale for the Concordat is described as:

‘concerns about the way in which health services, social care services and police forces work together in response to mental health crises. Where there are problems, they are often as a result of what happens at the points where these services meet, about the support that different professionals give one another, particularly at those moments when people need to transfer from one service to another.

This is a very serious issue – in the worst cases people with mental health problems who have reached a crisis point have been injured or have died when responses have been wrong’ (Ibid page 6).

The expectation was that local partnerships of health, criminal justice and local authority agencies across England would agree and commit to local Mental Health Crisis Declarations. These consisted of commitments and actions at a local level that delivered services that meet the principles of the national concordat. Partners in the Southwest Peninsula signed the local Concordat in December 2014 declaring amongst other provisions that:

‘Everybody who signs this declaration will work towards developing ways of sharing information to help front line staff provide better responses to people in crisis’.

Partners in Devon created an Emergency Mental Health steering group with a range of partners including DPT and Devon and Cornwall Police. Resources created from the local concordat include First Response and the Moorings and a health-based Place of Safety.

Compliance with section 140 of the Mental Health Act (see below) was also intended by the multi-agency partnership but it is unclear whether this was achieved.

The street triage service together with liaison and diversion services in the custody suite enabled police and mental health services in Devon to meet the key principles of the Crisis Care Concordat, improving liaison and joint working by the police, acute health and mental health services

Police and mental health services now work together in a different way from 2012. The Devon street triage pilot was one of the initial nine national street triage pilot sites set up in 2014.

In Devon, mental health professionals now sit in the police control room, sharing information in real time. An AMHP can attend a scene (the Pappa 99 car) during an incident to provide advice and intervention with a person who is mentally unwell.

The mental health liaison and diversion team was set up in Devon in late 2013. This team of mental health professionals are based in custody suites across Devon and offer assessment of detained people who may have mental health, learning disability or substance misuse issues. They advise custody staff on how to support the person.  

Whilst no Mental Health Act (MHA) assessment took place for Thomas in 2012, had it done so there may have been issues regarding the availability of a bed. Practitioners and police colleagues from 2021 report that the availability of beds is much of an issue in 2021 as it was in 2012.

Both police and providers are concerned about the risks, to rights and safety, of trying to keep a person who cannot be detained under the MHA because there is no bed in a hospital available for them.  AMHPs are concerned that they are in a position where they cannot complete an assessment because there is no bed available.

Once every 4-6 weeks the Devon custody suites will experience a situation when AMHPs cannot sign the section papers in respect of a person liable to be detained under section 2 of the Mental Health Act 1983 because no bed is available anywhere in the country.

It is reported to take between two hours and two days to find a bed. During this time the police are left in a position of detaining a person without legal authority in the unsuitable environment of a police custody suite. The police are not able to release an individual because they know that the person is unsafe, and that the outcome of the initial mental health assessment is that they should be detained.

The police record these decisions citing Article 2 ECHR and the positive obligation to protect their life based on the mental health information received so far. They liaise with mental health colleagues as a priority to expedite a bed and use internal and external escalation processes to try to expedite the process. 

The systemic reasons for the shortage of mental health beds are explored in a report commissioned by the Royal College of Psychiatrists (2019). These are not discussed in detail within this SAR. Section 140 of the MHA 1983 places a duty on commissioners to notify local authorities in their areas of arrangements for:

• admitting people in need of urgent care
• people who need appropriate accommodation or facilities designed for children and young people under the age of 18

Thomas, and others in similar circumstances, appear to meet the criteria of being ‘in need of urgent care’.  

The Devon Crisis Concordat action plan (update on the delivery of the Devon Crisis Care Concordat Action Plan. The Devon Emergency Mental Health Steering Group (May 2017)) (updated 2017) contains an action to ensure compliance with MHA s140. This action was awaiting amendments to the Police and Crime Act.

The revised Mental Health Act code of practice (2015) identifies how the section 140 duty should be managed locally. The guidance in the Code proposed that local authorities, providers, NHS commissioners, police forces and ambulance services should make sure that a clear joint policy is in place for the safe and appropriate admission of people in their local area. This should be agreed at board level and each party should appoint a named senior lead.

A 2019 CQC review of the implementation of the code of practice identified that only two CCGs in England at that time had a section 140 duty policy.

Greater awareness, senior oversight and monitoring of information relating to section 140 processes could help patients, medical staff and approved mental health professionals to find mental health beds, avoid delays when people require admission to specialist settings and help inform the commissioning needs for alternative services, including crisis houses and community support services. It is not known if Devon currently has a joint s140 policy.     

6.3.4 How would practitioners in 2021 respond to a similar situation?

AMHPs of 2021 would look at the nature of Thomas’s mental disorder and not only the degree. They thought that on the basis of Thomas’s historical relapse pattern and behaviour when unwell, indicators of rebound psychosis, leaving the building and being unreliable about letting CRHTT in they would now consider applying for a warrant under s135 of the MHA 1983 in order to assess Thomas’s mental health in the designated health run Place of Safety in Exeter. This would ensure Thomas’s safety and minimise the risk he would be out in public when unwell.

Being in a Place of Safety is not the same as being under a section of the MHA 1983 when treatment can be given, the person still has to consent to treatment. Thomas’s capacity to make decisions about taking his medication could be assessed in the Place of Safety and, if he did not have the mental capacity to do so, a decision could be made by a psychiatrist using a Best Interests checklist whether to commence administering Clozapine or not (MCA). 

Such a decision may not have been so easily contemplated in 2012. There was no dedicated health run Place of Safety and mentally ill people on s135 or s136 were often detained in police stations.

In 2012/13, 74% of people were detained in police custody after being picked up under section 136 of the Mental Health Act. By 2017/18, that number had dramatically decreased to 2%. 2021 staff spoke positively about the Place of Safety and the comfort of the service to people who had been detained on s 135 or s136.

Caraston Hall staff report that when a person is threatening, they are told by the home treatment team that it is not safe for them to visit, yet untrained support workers are expected to hold this risk and the other vulnerable people in the house exposed to the risk of harm. In extreme situations other tenants move out and the person remains with staff who become exhausted and burned out.

The number of assaults against social care staff in their service has increased and there is no emergency accommodation where a person can be placed if they are not unwell enough to be detained under the Mental Health Act or no bed is available. 

Caraston Hall and other providers do experience an understanding and supportive approach from the community mental health teams (CMHTs). They would recommend that CMHTs operate over a seven-day period, this could increase continuity of care and support – essential during relapse.   

2021 staff focused on sharing information with the ambulance trust about what approach to take should Thomas leave the building and be unwell in a public place.

DPT information governance processes require the DPT information governance team to make decisions on whether to share information. DPT staff were aware that information sharing decisions needed to go through information governance, a mental health professional cannot make these decisions independently.

Mental health information sharing with the police is enabled by the presence of the mental health liaison and diversion team in the custody suite and the presence of mental health professionals with access to records in the police control room.

However, these are not 24/7 services. Liaison and diversion operates from 8 am – 6pm with an ‘out of hours’ protocol to either contact the forensic medical examiner or leave for L&D the next day.

Street triage can access a person’s mental health records so providing real time information and advice on incident logs that are coming through where mental health, distress or potential crisis are presenting factors.

Street triage can assist police call handlers and dispatchers as well as officers on the ground by providing an informed response and recommendations and advice on how best to proceed. They are physically deployed in police control rooms Monday to Friday 8am until 2am; Saturday and Sunday 10am until 2.00 am. Outside of these hours, or when a shift is unfilled, there are alternative contact numbers, in Devon this is the mental health single point of access number which is 24/7.  

Caraston Hall are beginning to build relationships with local police so that people who live on the premises are known by officers who may attend the premises as individuals who experience difficulties at times.

6.4 3 October 2012

6.4.1 CRHTT requested a Mental Health Act assessment from the AMHP hub on the morning of 3 October. The Caraston Hall support worker saw Thomas that morning, he appeared unwell. The support worker spoke to the Crisis Team who told him that they were coming out to do a mental health assessment that morning.

Thomas went out, saying that he was going to church but that he would be back in time to see the psychiatrist at 11:00am. Thomas appeared to be in a hurry and was wearing dark sunglasses and a cap.

The AMHP service began to set up a Mental Health Act assessment. Caraston Hall staff provided contact details for Thomas’s family, these details were not on Thomas’s DPT notes and do not appear to have been subsequently added. Thomas’s nearest relative, a family member, had no objection to Thomas being detained under the Mental Health Act if required. 

At 11.50, the Mental Health Act assessment team convened at Thomas’s accommodation. Thomas was not at home; his support worker went out to look for him. The team stayed for half an hour to see if Thomas would return. Their new plan was to:

1. Abandon clozapine titration, as the nursing staff are not convinced he took his clozapine last night.
2. Continue to offer amisulpride.
3. Continue to try to see him face to face for mental health act assessment.

After Thomas left Caraston Hall at around 10 am it is believed that he made his way to his church. On the way he allegedly assaulted a man, punching him in the face and kicking him. This matter was not reported to the police until 5 October and was not known to officers arresting Thomas later that day. 

Thomas then went to the church where he had not been seen since 28 September. He arrived a third of the way through the service, breathless and talking loudly and bizarrely. He did not seem at all like his usual self. He stayed for communion and told the vicar that he had to return to Caraston to see his support workers at 11am.

Thomas then made his way to the High St. where according to witness accounts he struck a man of Asian appearance on the head whilst shouting that the man had a weapon. Various accounts describe Thomas as shouting ‘drop your weapon’, being in a boxing stance, skipping and shouting in the street.

A male passer by intervened to draw Thomas away from the man whilst two telephone calls were made to the police.  An incident log was created at 11.02am by the force control room operator within Devon and Cornwall Police. The call was logged as an immediate response and concerned ‘a male accosting members of the public’.

Member of public 1 gave the operator a description of Thomas and said that Thomas was claiming that members of the public were carrying weapons, when they were not.

At the same time another member of the public called to report “a male kicking off” on High Street, Exeter. Neither of the callers referred to observations that Thomas may be experiencing mental health issues.

The second call was again classed as an immediate response and a second incident log was created. This incident log was used as the master log upon which to record the ongoing incident, with the initial incident log cross referenced to this one.

This was thought in 2021 to be unusual, the first log is usually the master log, and risks confusion about what is happening at the time of the report. A member of the public also alerted a PCSO and PC who were around 150 yards away from the scene and the first to arrive. PC 1, the first officer at the scene restrained Thomas almost as soon as he arrived on the scene.

Thomas actively resisted the officer’s restraint and a struggle ensued which resulted in Thomas being restrained on the ground and being handcuffed behind his back and put into leg restraints.

A further four PCs and one PCSO attended between 11.05 and 11.08. An update was received by the control room at 11.07am from PCSO 1 who informed the operator that the male was restrained outside a shop and it appeared he may have assaulted someone. 

Thomas was arrested at 11.12 am on suspicion of committing an offence contrary to section 5 of the Public Order Act. Once Thomas had given his name, a Police National Computer (PNC) check was undertaken, but there were only warning markers for drug use from 2001 and an information marker for offending on bail. There was no information about Thomas’s mental health, his current mental health crisis or risk assessment/management advice.

During this period Thomas was reported by police officers and witnesses to be agitated, kicking out, swearing and making growling noises. He threatened to bite officers, or bite them and kill them, and was producing a great deal of spit. Thomas was reported as being calm and then being very agitated and breathing heavily.

Officers later reported during the IPCC investigation (IPCC Report 2012/016815) their thoughts about who Thomas was or what might be happening. He was physically strong and had a screwdriver in his pocket, had he been working on the building site? He had £400 in cash on him, officers thought possibly proceeds from a drug deal and was Thomas under the influence of drugs? 

The arresting officer stated that he did not have any reason to suspect that Thomas might be mentally ill. Two police colleagues did consider this however, one remarking that he was surprised that the PNC check showed nothing about mental health concerns.

Thomas was lifted by four officers with one holding his head to prevent injury to him and to stop him biting anyone. Thomas was still threatening to bite and kill officers at this point.

He was being carried face down as officers thought that he would spit, his mouth was ‘full of spittle’ and was placed slowly into the van feet first and left in a foetal position on the floor of the van. Other police officer accounts report Thomas as being slumped with his back against the door.

The IPCC report recorded that Thomas was turned onto his back before entering the van. At 11.11 am, the van left for Heavitree Road police station. The officer driving was unable to see Thomas. Thomas was described as quiet for most of the way. It took seven minutes to arrive at the police custody suite.

The van arrived at the police station at 11.18. Thomas did not leave the van until 11.21, he was still hand-cuffed, and a leg restraint still applied above his knees. His lower legs were restrained again as he kicked out and a ‘Emergency Restraint Belt’ (ERB) was applied around Thomas’s face by custody officers at 11.23 when he threatened to bite.

Just before the ERB was applied, his shoulder was knelt on and his head held down on both sides. Thomas was carried to a cell by four officers and placed face down on the mattress. He was held in this position for over four minutes whilst officers searched him.

He is reported to have stopped struggling at 11.27. The ERB was removed at 11.28 having been in place for five minutes. Officers left the cell; Thomas was lying on his front on the mattress. 

The custody record on Thomas was opened by Custody Sergeant 1 at 11.29 am. His offence was recorded together with the circumstances of his arrest as reported to the custody sergeant. Thomas “.. was shouting and screaming in the street. Appeared aggressive in his nature. Clearly causing harassment, alarm and distress to the public. Restrained and arrested”.

The custody sergeant authorised Thomas’s detention at 11.30 am, it was recorded that the detained person (DP) was not present or informed for the reasons for the detention. Thomas’s demeanour on arrival was recorded as “uncooperative, under influence of alcohol/substance, violent”.   

Custody staff looked through the cell door hatch on three occasions, entering the cell at 11.41 am. The healthcare professional in the custody suite observed Thomas through CCTV but did not observe his condition through the hatch. 

An ambulance was called at 11.42 and CPR commenced. The paramedics arrived at 11.47 am. Paramedics attending Thomas found him collapsed. They initiated Advanced Life Support protocols and he was treated with oxygen, naloxone (it was unclear what was wrong and so naloxone for opiate reversal was used as a precaution) and adrenaline. A second ambulance arrived at 11.50 am. By 12.12 pm, Thomas had arrived at the hospital and was transferred to the intensive therapy unit.

The Custody Sergeant completed a custody officer assessment form at 12.12 pm. It was recorded that:

“upon arrival at the Custody Unit this DP was clearly too violent, drunk and/or uncooperative to enter the charge room and I directed that they be taken to the cell using Primary Control Techniques. This use of force was necessary, proportionate and lawful as there was no other safe method of placing the DP into the cell. An Emergency Response Belt (ERB) was used on his face as a bite-guard, as the DP had shouted, several times, that he was going to bite officers”.

The custody sergeant ticked unknown in relation to whether Thomas appeared injured or unwell. He also recorded that he could not “see any evidence of any injuries at this time”. However, he did tick the box to say that first aid and/or medical treatment and a healthcare professional (HCP) was required.

6.4.2 Analysis

Thomas’s presentation to the police could have been explained by an understanding of his mental health condition. He was salivating heavily potentially as a side effect of his medication. He was threatening to bite and kill, he thought that he might be a vampire.

Thomas also thought that he was somehow party to information about a plot to smuggle weapons and was suspicious of Asian men. The police were completely unaware of this information.

We have no sense of what he might have made of the police and being restrained. The absence of information sharing in this instance was a lost opportunity to give vital information which may have prevented harm to Thomas when in public.  

The police may have had to restrain Thomas at some point if other approaches had failed. The subsequent IPPC investigation found that no other approaches had been tried. Thomas was not given the opportunity to calm or orientate himself by the officer who first arrived on the scene.    

‘This investigation has concluded that PC1 …. acted with undue haste in moving to use force and arrest Thomas and that his actions were neither reasonable or proportionate……the evidence also suggests that he failed to properly assess Thomas’s mental state or give proper consideration to a lesser intervention.

Insufficient attempt was made to calm Thomas by talking to him. On his own evidence it is apparent that PC 1 did not consider if Thomas may have been suffering from mental illness.. It appears from the evidence that PC 1 had the opportunity to make a much greater attempt to engage with Thomas than he did and so he failed to assess properly the situation he was dealing with. This was a lost opportunity which would have allowed PC 1 to consider other methods of dealing with the situation, including verbal communications or seeking medical assistance, rather than the forceful actions he took’.

The lead reviewer agrees that this was a lost opportunity to change the course of events. By the time other police officers arrived Thomas was still very agitated, one officer noted that he seemed to have ‘gone beyond reason’ and could no longer be calmed.

The Custody Sergeant also did not consider whether Thomas might be in a mental health crisis. Despite no indications to confirm these assumptions he considered Thomas drunk or under the influence of another substance.

The conduct of custody officers reached the threshold for criminal prosecution and the custody sergeant and two custody officers were charged with Thomas’s manslaughter by gross negligence, being found not guilty in 2017.

In April 2018, the Office of the Chief Constable of Devon and Cornwall Police pleaded guilty in respect of breach of section 3 of the Health and Safety at Work Act 1974 in relation to the use of the Emergency Restraint Belt in Thomas’s detention on the basis that the breach did not contribute to the death of Thomas.

The ERB was primarily used as a limb restraint and was manufactured as such.  The manufacturers advised that it could be used as a spit or bite guard, but only placed loosely around the face and when the person was in an upright position. In 2002, it was approved for use as a spit or bite hood by Devon and Cornwall Police and its use as such continued until Thomas’s death when the force suspended its use as a spit or bite hood. Only custody staff were issued with the ERB and trained to use it in this manner.

The IPCC investigation report noted that the vehicle that was used to transport Thomas should have only been used to transport a compliant person, not someone who is agitated and under the restraint that Thomas was. The vehicle gave officers no opportunity to monitor a person under restraint for signs of illness and/or positional asphyxia.

It was a recommendation from the IPCC investigation that Devon and Cornwall Police should re-consider and monitor the use of the type of van for the transport of non-compliant prisoners in the future.

6.4.3 What has changed since 2012?

Custody units now benefit significantly from in person reviews and assessments of vulnerable detainees by the Liaison and Diversion team mental health professionals. This is an extremely valuable resource which custody staff use to inform risk assessments, custody care plans as well as ensuring the person’s safe transfer to an appropriate health facility or to arrange services post release from custody. Liaison and diversion mental health staff provide training in mental health to custody staff.

A South west peninsula section 136 protocol was agreed by Devon and Cornwall Police, the councils and health commissioners and providers in 2014. 

This protocol spells out actions officers must take, including contacting street triage, when encountering a person who may be in a mental health crisis. The protocol has not been updated since 2014 and does not reflect the current practices or policies in mental health. It’s use is reported to be sporadic.

A revised protocol has been developed and should be published in 2021. Commitment to clear partnership working with people in mental health crisis must be demonstrated through timely attention to keeping operational protocols up to date.    

An independent review into deaths in custody was commissioned by the government in 2015. The review report (Angiolini 2017) made key recommendations regarding the frequent context for death in custody including restraint practices with people who have mental health issues.

Devon and Cornwall Police have adopted the recommendation from the independent review that mental health training is vital for officers working with detainees in police custody.

Liaison and Diversion services deliver training which covers some of the mental health issues that may be seen in the custody suite, exploring the possible signs, issues, behaviours and strategies to assist with looking after them. There is an understanding and appreciation of the impact that being in police custody can have and also strategies as to how to make the experience more comfortable and less anxiety inducing.

As Dame Angiolini also noted in her report, working alongside mental health professionals increases the understanding of custody officers.

During training, police officers and custody sergeants are given a medical input on recognising the potential signs of ‘acute behavioural disturbance’ (ABD).

Acute behavioural disturbance is an ‘umbrella’ term for the clinical presentation of a number of conditions (Royal College of Emergency Medicine (2019) Acute behavioural disturbance (ABD): guidelines on management in police custody). The term is used in emergency services, police and ambulance, to describe a state of hyperthermia (hot to the touch), agitation and aggression.

ABD may be associated with fatality even when appropriately treated, but the likelihood of successful treatment is increased with immediate appropriate medical interventions. Attempts to de-escalate the situation should always be attempted and minimum restraints used.

During initial and refresher training, all police officers and custody staff are also taught conflict management including relevant risk assessments, de-escalation strategies and techniques, communication skills, avoiding Positional Asphyxia, head injuries, and the medical implications of the use of police equipment.

They have a module on self-management, officer behaviours and the effects of stress and conflict. These subjects are included again in refresher training.

Training takes account of the death in custody review (Angiolini 2017) first recommendation:

Recommendation 1 Police practice must recognise that all restraint can cause death. Recognition must be given to the wider dangers posed by restraining someone in a heightened physical and mental state, where the system can become rapidly and fatally overloaded. Position is not always the determining feature. As great a danger can arise from the struggle against restraint as the restraint itself (Ibid page 27). 

Since 2018, all training on restraint practices has included the use of the safety officer role to ensure that the welfare of all individuals restrained is prioritised. This allows an officer or staff member to assign themselves as safety officer to monitor the individual throughout the period where they are restrained.

Officers are refreshed on a yearly basis on the use of hand cuffs, soft restraint belt and Velcro limb restraints. The refresher training covers Positional Asphyxia and the use of the safety officer.

6.4.4 How would practitioners in 2021 respond to a similar situation?

Mental health practitioners in 2021 would record that Thomas was not present for the MHA assessment together with his risk assessment and management plan immediately so that this was available to mental health practitioners in the police control room.

They would also ring and discuss the situation with the Liaison and Diversion (L&D) team as they believed there was a strong risk Thomas may come into custody. They would have done so the day before his assessment in the knowledge that Thomas’s mental health was deteriorating, and he was not staying at home.

Police officers attending Thomas would be given details about the best way to calm him once his name was known. L&D staff would brief custody staff as to the best approach to take with Thomas. L&D staff reported that ‘they do this routinely’ and noted that through training and work with mental health colleagues the police’s knowledge and confidence in working with people in mental health crises had improved.

Mental health staff said, ‘it works well, communication is better, the custody staff know who is coming in and can be prepared and know the plan for the person’. 

Police officers of 2021 recognised a range of risks on receiving initial information about Thomas. The time of day can be significant in terms of who is on the High Street, the public may on one hand be hurt or traumatised, on the other they may attempt to intervene and risk injuring Thomas or themselves.

Police staff wanted to get the situation quickly under control and, as the incident was taking place in the city centre they thought that they would have a lot of resources to deploy. Their approach involved using police resources to move people away from Thomas and standing down extra resources whilst giving Thomas ‘time and space’ to see if he could calm down.

This would also give an opportunity to observe Thomas and try to see if he were in crisis. They could call an ambulance and/or ask for assistance from street triage.

If they had Thomas’s name, then street triage in the police control room could access his mental health records and advise accordingly. In the times when street triage was not available they were aware of alternative numbers but thought that these were not always successful.  

Officers described the relief they felt when the ‘Pappa 99’ car arrived, a police vehicle with an AMHP and police driver. Officers said that they were not mental health professionals and worried about doing or saying the wrong thing.

AMHPs are mental health professionals and are confident in their decision making, officers talked about learning tips on talking with people in crisis, what questions to ask from observing the AMHPs in action.

Police officers are clear that whether to use section 136 is their decision, but they were able to get ‘live’ information from street triage and consult with paramedics. The health run place of safety would be the destination if s136 was used. 

A paramedic was once part of street triage, but this has not been possible to provide at present, calling out a paramedic from the incident has been a reasonable substitute. 

Officers identified de-escalation techniques they would use to try to engage and calm the person. All staff spoken with, who either worked in the community or custody suite were concerned about the possibility of ‘ABD’ and said that they were trained in recognising this and managing this situation.

Whilst with the person they monitor the person’s breathing/chest by sight. If ‘ABD’ was a possibility the person would need urgent conveyance to hospital.  

Officers were clear that if attempts to calm the person failed and there was a risk to the person, public or officers, then restraint is an option.

A key difference from practice in 2012 is the ‘safety officer’ role.  All officers are trained to undertake this role, and in any restraint one officer is appointed as ‘safety officer’ and their specific role, to monitor the person’s condition, identify any changes quickly and alert any possible deterioration in health, is understood by other attending officers. The safety officer is positioned at the person’s head.

Unlike 2012, officers have body cameras which must be turned on during incidents on the street and use of restraint etc. Devon and Cornwall Police Constabulary adopted body cameras for officers in 2018. 

Restraint equipment is used to handcuff the person behind their back, and limb restraints if the person is kicking or hitting out at others. Limb restraints are checked for tightness and the time they are applied is logged, they must be checked every twenty minutes.

If the person is spitting at police officers a spit hood is applied, a mesh fabric hood fastened at the neck. Devon and Cornwall Police introduced spit hoods in 2019 and use these in custody suites and public places.

The use of spit hoods is controversial, whilst police and custody staff need protection from bodily fluids the practice is also thought to be degrading, and cause panic in potentially already physically and mentally stressed detainees.

Police staff of 2021 are concerned to protect a person’s dignity in the use of the spit hood, for example making sure that the person can see.            

If a person is fully restrained they will be lifted by several officers, 2021 staff are aware that using multiple officers can look oppressive to onlookers. The purpose of a multiple officer lift is to reduce injury to the person, they could be dropped or mishandled, and to reduce back injuries to officers.

Police and custody staff of 2021 avoid putting people in a prone position. If waiting for an appropriate vehicle for transport they will place the person in the recovery position or sit them up if they are able to cooperate.

Police officers are concerned that in some vans used for transport they are not always able to avoid the prone position. If a person is distressed an officer will sit in the back of the van with them.   

The custody suite is advised of the condition of the person and use of restraint prior to transport. 2021 custody staff said that it was not uncommon for L&D mental health professionals and health care professionals to observe the person’s arrival at the custody suite, speak with the safety officer and advise the custody sergeant of their health and welfare observations.

When authorising a person’s detention custody sergeants must undertake a risk assessment and ask L&D and healthcare professionals to assess if there is any concern about a person’s mental or physical health.

Custody staff said that should the advice be that the person should be taken to hospital that advice must be immediately acted upon.

Some cells in the Devon custody suites have extra measures incorporated into them for ‘vulnerable’ people. In February 2021, ‘Oxehealth’ monitors were installed in 18 cells across the force (https://www.thepost.uk.com/article.cfm?id=115767&searchyear=2021), these monitor movements of the chest and diaphragm, calculating the persons breathing rate and providing an early alert to health issues.

Devon and Cornwall Police’s use of the system in custody cells is the first of its kind in the world. In addition, these cells have a clear panel in the door for high level observation.

Custody officers said that they value the L&D team’s presence, appreciating the information and expertise these mental health professionals can provide. However, the service is only available between the hours of 8 am until 6 pm.

Custody staff would appreciate an extension of these hours up until 10pm as mentally unwell or learning disabled people are frequently detained during evenings. Senior staff would appreciate an L&D provision that matches the 24/7 healthcare practitioner provision in the custody suite. 

Whilst provisions exist to support close working and information sharing between police and mental health services, they do not cover all hours of the day and are sometimes left unstaffed in times of pressure or limited mental health staff availability.

Police representatives report that people detained in custody may not always receive individual management in the way the s136 protocol intends or specifies because L&D staff are not present.

Outside of the liaison and diversion hours the custody suite healthcare practitioners in the custody suites cannot access mental health records and street triage have asked that they are not contacted in these circumstances because this will limit their capacity to manage the existing control room demand.

Staff report that at peak times including over the busy summer months the street triage team can be overwhelmed and the incident log demand outstrips their capacity.

Occasionally street triage shifts will be unfilled. Outside of their working hours it is necessary to ring a single point of access number who may not always be able to assist quickly.

6.5 After Thomas’s admission to hospital.

6.5.1 At 9 am on 4 October, Thomas’s care co-ordinator went to ITU to ask for an update on his condition. The care coordinator was told that Thomas’s condition was ’critical’ but that ward staff could not talk to anyone other than the police and Thomas’s immediate family.

The Manager from Caraston Hall called the care coordinator for information. The care coordinator was told that they could not give anyone information but to direct Caraston Hall to write to information governance for information.

The care coordinator returned the manager’s call and apologised about being unable to give information and said that Caraston Hall needed to write to information governance for access.

The Caraston support worker was a key link between Thomas and his family – but the family say he broke off all contact after Thomas died. It Is not known how the support worker’s manager supported him in this matter, and we do not know how the cessation of any information sharing with the mental health trust was interpreted by Caraston Hall.

Thomas died on 10 October 2012.

DPT completed a Root Cause Analysis (RCA) on 6 December 2012. Neither Thomas’s parents nor Caraston Hall were involved in the RCA. The report explains that ‘Thomas’s parents were not contacted for the purpose of this review. He had little contact with them; no contact details were available on RiO (Thomas’s record).’

Thomas’s family say they had no support until they began working with Inquest. Thomas’s family have had to focus on what happened to Thomas whilst he was arrested and detained by Devon and Cornwall Police in the eight years since his death. They have been through several court processes over these years. They still have unanswered questions relating to Thomas’s care from DPT.  

6.5.2 Analysis, including what has changed since 2012 and what would happen now?

The DPT RCA did not include any other agency working with Thomas at the time. As such it could only find partial learning from events leading to Thomas’s tragic death. It did not recognise the need to urgently communicate risk information and management advice to other agencies or therefore use that learning to find mechanisms to do so.

The thematic review of 2015 recommended that the Root Cause Analysis process should include multi agency participation and independent oversight in the review where there has been multi agency involvement in the incident.  DPT have incorporated these recommendations in the root cause analysis procedures (https://www.dpt.nhs.uk/download/SqMD0oHXos).

DPT report that they now involve families in Serious Incident Reviews. Their current process notes that:

Most importantly the investigation, where possible, will involve working with the person involved, their carers and family so that their experiences, concerns or views can be considered and reflected in the investigation report. In the first instance, and where appropriate, when there has been a bereavement, we will normally contact the identified next of kin to agree how they or others may want to be involved.

When families do wish to be involved in the RCA process an RCA Lead will:

• make contact with the family or carers early on and arrange for a meeting (or other method) for them to be involved
• provide a point of contact for the family
• be open and honest about what has happened, share this with family members and address any specific issue that the family have
• know the details of the case
• offer meaningful involvement in the production of the RCA report
• be professional – if a carer or family member chooses not to be directly involved in the investigation, we will always offer them the chance to receive a copy of the final investigation report for their information

Thomas’s family needed to be aware of possible support services soon after Thomas’s death. Dame Angiolini (2017) recommends in her report that:

‘All state agencies who are engaged with the family, including police, IPCC, CPS and Coroners and their staff should provide both oral and written information about support services, including INQUEST, to families as early as possible when contact is established following the death. Agencies should not assume that this has already been done by others’.

It is not clear whether these recommendations have been followed in Devon.

Staff from different organisations who have worked together with a person who has died need to be able to de-brief together and support each other.

Whilst Caraston Hall have set up a debrief/lessons learned process with a specialist facilitator if the person has died, they recognise the need to have joint debriefing sessions with CMHTs or other mental health colleagues.

Whilst the two agencies have people in common, they do not work together to help to identify process and system errors. It is likely that had DPT and Caraston Hall worked together after Thomas’s death more would have been done to support Thomas’s family who, unbeknown to the mental health trust, were very aware and concerned about his life and progress. 

7. Findings and learning points

The findings and learning points below relate to governance of the SAR process; the events of 2012 and the responses given to the questions the review has asked about the situation in 2021.   

7.1 The SAR process has been challenged by governance issues dating back to 2013 when the potential for a Review was first identified.

The organisations involved were not asked to secure records and as a result the learning from the SAR has not been informed by a full range of records from that period.

The current TDSAP SAR policy does not refer to the necessity of securing records when a referral is received. 

Learning point 1: There may be a long period of time between the SAB receiving a referral and the decision to commission a SAR. It is important that the organisations involved are asked to secure their records and are kept informed of any decisions to delay the Review.

7.2 The purpose of an SCR or SAR is learning with the intention that learning should be applied as quickly as possible in order to implement measures to prevent risk to adults.

Whilst it was not possible to learn from the actions of the police at an earlier stage it was possible to examine the role taken by other organisations.

This learning could have informed the development, dissemination and implementation of the innovations in practice bought about by the Mental Health Crisis Concordat in 2014.

Learning point 2: The fundamental purpose of a SAR is to ‘seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again’ (Care and Support statutory guidance chapter 14 section 168).

This principle and the urgency of applying learning must be borne in mind when considering SARs in the future. There may be a creative way of achieving learning without obstructing other processes.

7.3 Thomas’s care coordinator and support worker used good practices in the way they worked together to his benefit.

However, mental health practice in Thomas’s case was poor with regard to risk assessment and management, understanding and use of the Mental Capacity Act 2005 provisions and decision making on the part of the mental health trust. 

A significant lost opportunity was the failure to share information with Devon and Cornwall Police Constabulary about Thomas’s risk profile together with risk management advice in the light of knowledge that Thomas was going out in public and was likely to present a risk to himself and others.

7.4 The practices used by Devon and Cornwall Police in 2012 were criticised by the IPCC report of the time, officers had not followed policy or practice guidance in their initial response to Thomas.

A significant lost opportunity was the failure to try to speak with or calm Thomas, to try to ascertain what might be the reason for his behaviour. A second opportunity to do this may have been taken when Thomas arrived at the custody suite but instead assumptions were made about his behaviour and his restraint was continued and amplified with the use of the emergency response belt.

7.5 A great deal has happened since 2012. We will now consider these findings under the questions posed by the SAR Panel:     

7.5.1 How are provided services supported to ensure the safety and wellbeing of a person experiencing a mental health crisis, and others in the same household?

Provider services can be supported by a home treatment team and out of hours or 24/7 helplines. It is possible to increase support hours quickly during a crisis.

But there are still occasionally situations when a person is deemed ‘unsafe to visit’ by mental health services but continues to live in accommodation with other people who have mental health issues and are supported by non-qualified staff. CMHT staff are found to be a consistent source of support in such situations but do not work over weekends.  

Learning point 3: Supported living providers are part of the mental health system and should not be left to take risks that are unacceptable to other organisations.

There is a need for a focus on these situations from commissioners, trusts and providers with the aim of creative problem solving to the benefit of people who live in supported accommodation or residential care and their support staff.

7.5.2 How are existing risk assessments utilised and updated when a person experiences a relapse or mental health crisis? How is contingency planning utilised? Which agencies are alerted, how and in what circumstances?

The expectation from 2021 staff is that risk assessments are ‘dynamic’ and continually updated. They can be shared via the mental health teams who work alongside Devon and Cornwall Police Constabulary if a person comes to their attention.

Unless adult safeguarding issues are identified other agencies are not alerted without the person’s consent, a proportionate measure which respects rights.  Contingency plans are recorded, and efforts are being made to ensure that DPT patients are involved in the creation of a ‘My Future Support Plan’. 

2021 staff appear very aware of the impact of loss of mental capacity and the need to discuss actions to be taken in this eventuality.   

Learning point 4: Efforts must continue to involve people in discussing contingency plans as well as other aspects of their care and support. That 50% of inpatients surveyed have contingency plans is not yet a significant indicator of widespread practice.   

7.5.3 Interagency information sharing: Are the police and mental health services currently able to communicate potential risk to the person and public in real-time? What mechanisms and protocols support this? What impact did the crisis care concordant have on information sharing or communication between agencies in Devon?

The 2014 Mental Health Crisis Care Concordat bought together and built on a number of pilot schemes in Devon and the wider Peninsula, creating an excellent connection between police and mental health services via street triage and liaison and diversion teams.

When these services are operating it appears that police and mental health services can communicate potential risk in real time as mental health records can be accessed by staff employed by DPT and appropriate information shared.

There is a danger of complacency about this mechanism of information sharing, street triage shifts are not always filled, or staff are under too much pressure to respond to urgent requests for information at certain times of the year. Liaison and diversion services stop at 6 pm.

The s136 joint protocol for use of s136 which underpins many of these and other significant arrangements between the police and mental health services had not been updated since 2014 and was unfit for purpose and is reported to be inconsistently adhered to.

It is unclear whether some of the actions agreed as part of the local 2014 crisis concordat have been completed, including the multi-agency section 140 policy. A white paper on the reform of mental health legislation is published and new legislation awaited.

The crucial importance of partnership working in mental health is such that existing arrangements need continual monitoring and review. The Peninsula s136 protocol has now been revised, when available it is important that it is correctly disseminated and understood and it’s use monitored carefully.   

Learning point 5: It is important not to be complacent about how good arrangements are working. Joint protocols and arrangements need monitoring and reviewing, gaps will appear over time and may go unnoticed until there is a serious or fatal incident. There are currently gaps in the ‘real time’ information sharing systems between the police and mental health services.    

7.5.4 Frontline police officers: How are officers trained and supported to a) defuse conflict or violence and b) recognise people who are experiencing mental health crises and assess or use the most proportionate approach to the situation? c) access support from mental health services?

Police appear to be trained with an emphasis on risk of ‘ABD’ and the need for a calm space and discussion. They have a range of techniques and processes to use in de-escalation. Knowledge and support to recognise and work with people who have mental health issues is reported to have developed via the interaction and joint working with mental health services as well as specific training.

Proportionate responses are supported by this increase in knowledge and confidence.  Frontline police officers can access support from mental health services, but the readiness of response can be curtailed by pressures on street triage or unfilled shifts.

Learning point 6

The street triage service is essential to the police response to people in mental health crises. It is vital that this service is maintained at capacity and the reasons for unfilled shifts addressed.         

7.5.5 Custody staff: How are custody staff trained to a) defuse conflict/violence and b) recognise people who are experiencing mental health crises and assess or use the most proportionate approach to the situation? What access do custody staff have to support from mental health services?

As above, custody staff benefit from the same training in defusing conflict as frontline police officers and their response to people with mental health and other issues of vulnerability benefits greatly from access to the Liaison and Diversion mental health team. Custody staff have ready access to advice and guidance from mental health professionals, but only between the hours of 8 am – 6 pm.

Learning point 7

It is essential that mental health support to custody suites is available at the times when people with mental health issues are likely to be detained. Custody suite staff advise that increasing the provision up until 10 pm will address the need for specialist advice and guidance at crucial times.      

7.5.6 How have restraint practices changed since 2012? What systems are in place to promote the welfare of all person’s subject to restraint or detention by Devon and Cornwall police?

Some practices have changed – the use of a ‘safety officer’, for example, and awareness of the importance of avoiding the ’prone position’.

The Emergency Response Belt has not been used as a spit and bite hood in Devon and Cornwall police since 2012.

In terms of safety in custody suites, cells with oxehealth monitors and enhanced camera and screen monitoring are useful measures, Devon and Cornwall have made innovative strides to increase safety in custody suites.

Police in the community are still concerned that some vans in use make it hard to avoid the ’prone’ position. The use of ‘spit hoods’ is controversial and may increase risk to people with mental health needs in crisis.

Learning point 8.

Restraint practices may still have gaps in how they are used. It may be useful to review how appropriate vans are available or deployed. Because the use of spit hoods is controversial the SAB may be interested in understanding when and how they are used when people are thought to be experiencing mental health crises.     

7.5.7 How are families supported after similar incidents with a tragic outcome? How do we support each other?

Thomas’s family needed much more support than they have been offered by organisations aside from Inquest in the years since Thomas’s death. They have not given up in their search for answers but appear to have had no support from any organisation in Devon.

It is important to remember that a person’s family may not have been central to their adult life, but family bonds are incredibly powerful, people must not be excluded from investigations on the assumption that they are thought to have played little part in an adult’s life.

It is helpful to a review or similar process to include a person’s family who will often have information and perspectives to offer that the professionals cannot.

The family themselves can also benefit from having questions answered and knowing that steps are being taken to make sure that practice and systems are being improved by learning about the circumstances around their family member’s death.

DPT now involve families in post-incident reviews and do support them through the days after a tragic event. It is now known how families are supported by organisations after a death in custody as recommended by Dame Angiolini (2017).

In contrast, families of victims of murder have a number of services to call upon including specialist victim support. Charities like Inquest have an in-depth knowledge of criminal, civil and coronial processes but are not familiar with SARs or RCA/significant incident processes and how all these processes might fit together.    

Learning point 9      

Families must be offered support after a death in custody, organisations should be confident in knowing where that support can be found, both locally and from expert charities such as Inquest who offer support throughout many processes. 

Learning point 10

SAB need to be aware of organisations working with the families of people who have died in custody, SARs are commissioned in response when the adult has care and support needs. National SAB networks can play a role in informing and advising Inquest and similar charities.

Learning point 11      

Organisations will benefit from joint debriefing after a tragic or serious incident. This will increase systems learning as well as enabling staff from different organisations who have worked together closely to support each other.

8. Conclusion

The review of the circumstances of Thomas’s tragic death 13 years ago has allowed us to consider how we would respond to a similar situation in the present.

The need for strong working relationships between all partners who work with people in mental health crisis is essential. These relationships need to be underpinned by relevant agreed protocols and arrangements which are monitored and regularly reviewed with the input of frontline staff and people who use mental health services.

There have been remarkable developments in how organisations work together, but we cannot be complacent about the success of these arrangements, they need to be continuously reviewed and developed to keep pace with the demands upon all services.  

Some potential issues with current arrangements have been identified by the SAR and recommendations made to address these. In addition, recommendations are made to the TDSAP regarding the SAR process itself.

9. Recommendations to the Devon and Torbay Safeguarding Adults Partnership

9.1 Recommendation:

The TDSAP is recommended to review and revise the Safeguarding Adults Review policy to include steps to advise organisations to secure records when a potential Safeguarding Adults Review referral is received.

Appendix C of the policy should also include refreshed guidance to include advice on Independent Office for Police Conduct investigations and court proceedings as potential SAR interfaces.

The need to commission a SAR in order to implement learning to prevent harm to people as soon as possible after an event should be emphasised together with guidance on potential approaches to enable this.

Learning points 1 and 2.      

9.2 Recommendation:

TDSAP statutory partners are recommended to facilitate a short-term working group including commissioners, mental health residential or supported living providers and the mental health trust to formulate pragmatic responses to situations when people in crisis are presenting risks to themselves, other residents or support staff and no ready solution is available.         

Learning point 3.

9.3 Recommendation: 

The TDSAP may wish to receive a report from Devon Partnership NHS Trust in one year regarding progress made in recorded contingency plans made with patients served by the Trust.  

Learning point 4.

9.4 Recommendation:

TDSAP is recommended to identify and ask partners to add details of organisations who can support the families of people who have died whilst in police custody to all local support directories.

Useful links can be made with national organisations such as Inquest through the SAB Chairs network or other national networks.     

Learning points 9 and 10.

9.5 Recommendation:

TDSAP is recommended to take steps to understand the risk assessments informing the use of spit hoods in Devon and Cornwall.

Learning point 8. 

9.6 TDSAP is recommended to receive reports from the organisations or partnerships in section 9 below regarding progress on actions taken in response to recommendations made by this SAR.  

10. Recommendations to individual agencies

10.1 Recommendation:

Devon Partnership NHS Trust, commissioners and Devon and Cornwall Police, together with partners in the mental health system, are recommended to review the existing arrangements used to facilitate joint working in community and custody suites with a view to:

• ensuring that the arrangements to provide information sharing and mental health advice are still fit for purpose and available to front line officers and custody staff when needed
• exploring the extension of liaison and diversion hours in the custody suite

Learning points 5, 6 and 7.

10.2 Recommendation:       

Partners in the Peninsula Criminal Justice Mental Health Group are recommended to ensure that the revised s136 protocol is supported by a dissemination and implementation plan which includes regular agreed monitoring and annual review with the aim of consistent use across Devon and the wider Peninsula. 

Learning point 5.

10.3 Recommendation: Devon and Cornwall Police Constabulary is recommended to address the concerns police officers have expressed about the availability of appropriate vans to transport restrained people to custody suites.

Learning point 8.

10.4 Organisations within the mental health system, in particular Devon Partnership NHS Trust and Caraston Hall Ltd, are recommended to develop a joint debriefing procedure so that staff can reflect and learn together after significant incidents so contributing to systems learning. 

Learning point 11.

10.5 Devon Partnership NHS Trust may, after considering the findings of this SAR, consider an apology to Thomas Orchards family regarding omitting to include them in the Root Cause Analysis of 2012.  

11. Glossary of terms used

• ABD – acute behavioural disturbance.
• AMHP – approved mental health professional.
• CCG – clinical commissioning group.
• CPA – care programme approach.
• CQC – Care Quality Commission.
• CRHTT – crisis and home treatment team.
• DPT – Devon Partnership NHS Trust.
• DSAB and TDSAP – Devon Safeguarding Adults Board, since 2021 Torbay and Devon Safeguarding Adults Partnership. 
• ERB – emergency response belt.
• IPCC and IOPC – Independent Police Complaints Commission and Independent Office for Police Conduct.
• L&D – liaison and diversion team.
• PNC – police national computer.
• RCA – root cause analysis.
• SAB – safeguarding adults board.
• SAR – safeguarding adults review.
• SCR – serious case review.
• SIRI – serious incident requiring investigation.