“My principal concern is that when a high-risk mental health patient is missing it…”

The coroner’s concerns

My principal concern is that when a high-risk mental health patient is missing it requires effective and meaningful multi-agency co-ordination. Locally, it engages BSMHFT’s Missing Patient Policy (which purports to append WMP’s missing person procedures), national College of Policing: Missing Person Authorised Professional Practice (‘APP’), and National Partnership Agreement: Right Care, Right Person (‘RCRP’). The evidence revealed significant gaps in knowledge, co-ordination and application of these policies. Specifically: 5 (1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-inCharge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. (2) A ‘monitoring tool’ in the BMSHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’. Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death. (3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’. (4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT. (5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP. I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date. (6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category. BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information. (7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. (8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person. Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it.

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, 2024-0296

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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