“[250-word statement addressing what circumstances of the death have led to the coroner’s…”

The coroner’s concerns

[250-word statement addressing what circumstances of the death have led to the coroner’s concern, and why the coroner thinks the person to whom the report is directed is responsible for taking action to prevent future deaths. This statement must not propose what action should be taken, as coroners cannot make recommendations]. Re: South London & Maudsley NHS Foundation Trust: It is recognised that the Trust has identified and put in train work that needs to be undertaken to address the issues that arose at the inquest. Much of the work has not yet been implemented or is not yet complete and until this is done the following remain as concerns: 1. Evidence was given at the inquest that although dynamic risk assessments were undertaken in advance of leave being authorised, risk assessments were not consistent with NICE Guidelines; 2. The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth which led to differences of understanding what had been agreed, the basis on which it had been agreed and by whom it was agreed. Documentation in respect of leave was incomplete and did not comply with policy. The nurse in charge was not informed of the decision for leave or the circumstances in which leave was granted; 3. The system for monitoring leave was inadequate, reliance being placed on hourly checks. The nurse conducting the hourly check at 12.00 when Catherine was due to return was not aware that she was on unescorted leave and did not escalate the matter to the nurse in charge with the result that the ward only became aware that she had not returned when her mother arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given to the patient before escalating the fact of them not having returned, with patients being given 30 minutes or more; 4. Ward staff appeared to take a different approach to leave and return depending upon the status of the patient as a detained or voluntary patient; 5. A photograph of the patient was not included in the grab pack. Unlike detained patients there was no checklist for voluntary patients as to the measures taken to locate the patient Re: Metropolitan Police Service: It is recognised that MPS has identified and put in train procedures to address the issues that arose at the inquest particularly in relation to the approach of MPS following a decision to transfer a CAD to the BCU MPU. The following remain as concerns: 1. An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted A476 A477 in a delayed deployment. Even where call handlers have real concerns that someone not returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to deploy is the same if the individual's address has not been visited, even when told that they would not go there. The way in which the policy was applied removed any discretion by call handlers and despatchers to deploy whilst checks at the address were being conducted. Evidence was given at the inquest that the call handler in the second call to MPS attempted to convey her concerns that there should be immediate deployment to her supervisors in despatch and was advised the police would not deploy; 2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at the home address of the patient in circumstances where the ambulance service will only attend an address if the resident is known to be there; Re: College of Policing: It was recognised by MPS at the inquest that there was an overly rigid approach to the Right Care Right Person policy and Affinity Protocol resulting from the robust application of the policy and protocol (see above). Some changes have been made within MPS within the parameters allowed given national guidance and standards, but evidence was given to the effect that training as to the application of the policy, protocol and toolkit could result in the professional judgement of call handlers/despatchers/supervisors being restricted resulting in delays to deployment 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1.Metropolitan Police Service 2.South London & Maudsley NHS Foundation Trust 3. College of Policing 4. Family of Catherine Morgan 5. South West London & St George's Mental Health NHS Trust 6. Kent Police I also have a duty to send a copy of the report to the Chief Coroner. A477 A478 You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026) Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. Signature RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 When a coroner sends a prevention of future deaths (PFD) report to a person or organisation, they must respond within 56 days. Recipients of a PFD report can apply to the coroner for an extension. A response to a PFD report must detail the action taken or to be taken, whether in response to the report or otherwise, or it must explain why no action is proposed. The purpose of the response template below is to promote clarity, ensure that responses address the coroner’s concerns directly and transparently, and support consistency and good practice across organisations and sectors. It does not restrict how a person or organisation formulates their response; recipients remain responsible for determ

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

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judiciary.uk, Prevention of Future Deaths reports, 2026-0282

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0