“Over the course of the inquest, it was quite apparent that few, if any, of the witnesses…”

The coroner’s concerns

– 1) Over the course of the inquest, it was quite apparent that few, if any, of the witnesses who gave evidence, including several employees of your Trust, were familiar with the version of the Mental Health Act Transportation Policy which was in force at the time of these events. This Policy governed the assessment of the risk involved in transporting a patient detained under the Mental Health Act 1983 ( the MHA ) to a psychiatric unit, and stipulated the measures to be deployed to mitigate that risk; 2) The witness who presented your Trust’s internal investigation report into the events surrounding Rosie’s death told the inquest: “None of our employees would have received specific training about the Transportation Policy – I accept that means this crew would not have known to ask for the Risk Assessment Tool [ an important document provided in the Policy to assess the risk posed by the patient to be transported ]. I would have thought they would have known to ask for the Written Authority to Transport [ another important document provided in the Policy, by which the Approved Mental Health Professional ( AMHP ) delegates responsibility for the detained patient to those transporting her ], as they do receive training about that. If they didn’t know about either of those forms, I accept that they may not have been an appropriate crew for this job.” 3) It seems that your Trust appeared at the time of these events to have had no system in place to ensure that those of your employees who dealt with the transportation of patients detained under the MHA were familiar with and trained to apply the provisions of the version of this Policy which was in force at the time. It is of concern therefore that if that remains the case, not only in relation to the MHA Transportation Policy, but in relation to other policies and procedures under the MHA, circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.

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, 2024-0246

Added to Minute Book

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