“The chain of command within the British Transport Police was broken unacceptably leading…”
Dated 15 Jul 2014, from the coroner for Berkshire. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 9 Sep 2014. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated15 Jul 2014
- Deadline9 Sep 2014
- Published on judiciary.uk15 Jul 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| British Transport Police | Response publishedPublished on judiciary.uk in July 2014. |
| Royal Berkshire NHS Foundation Trust | Response publishedPublished on judiciary.uk in July 2014. |
| Berkshire Healthcare NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 9 Sep 2014. A reply may have been sent and not yet published. |
| Thames Valley Police | Response publishedPublished on judiciary.uk in July 2014. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church. (2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley Area" (3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly. There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment. 1
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2014-0331
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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