19 Jan 2022

On the 5th January 2022, Dr Séan Cummings in his capacity as Assistant Coroner for Bedfordshire & Luton, issued a Prevention of Future Deaths Report following the conclusion of an inquest into the death of James “Jamie” Emmerson.

Natalie Csengeri, instructed by Courtney Smith of Duncan Lewis Solicitors, represented Mr Emmerson’s family.

This Regulation 28 Report was issued to a number of high-ranking people and organisations, including Sajid Javid (as Secretary of State for Health and Social Care),  the Association of Directors of Adult Social Services, the Royal College of Psychiatrists, the Chief Executive of the East London NHS Foundation Trust and the Director of Social Care, Health and Housing for Central Bedfordshire.

The Assistant Coroner provided a narrative conclusion after the investigation into Mr Emmerson’s death. This inquest concluded on the 14th of April 2021. Mr Emmerson was noted to be a male with complex mental health issues and on the 1st February 2019, he was detained under section 136 of the Mental Health Act 1983 to be taken to a place of safety, namely Jade Ward at the Luton & Dunstable Hospital.

Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place
of safety under this section may be detained there for…  the purpose of
enabling him to be examined by a registered medical practitioner and to be
interviewed by an approved mental health professional and of making any
necessary arrangements for his treatment or care”.

Unfortunately, although the purpose of this detention is for a person detained under section 136 to be examined by both a registered medical practitioner and to be interviewed by an approved mental health professional, Mr Emmerson was seen only by a registered medical practitioner, namely a lone section 12 approved junior doctor. He was not seen by an approved mental health professional prior to his discharge from the section 136 suite.

Following the evidence during this inquest giving rise to matters of concern, the Assistant Coroner formed the opinion that there is a risk that future deaths will occur unless action is taken.

The Assistant Coroner found that the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”) led to confusion as to the requirements of section 136.

At 16.50 of “The Code”, it stated: “If a doctor assesses the person and
concludes that the person is not suffering from a mental disorder then the
person must be discharged, even if not seen by an AMHP.”

The Assistant Coroner’s response to this reliance on this section of “The Code” during the evidence portion of the inquest was as follows:

“This was interpreted as meaning that assessment by an AMPH was not a
required formality. This was a deeply flawed interpretation but it is possible to
see where the ambiguity arises.”

It was noted in evidence that this was “custom and practice” both in Bedfordshire and Luton as well as in “other areas”. However, the Assistant Coroner in his Prevention of Future Death Report made it clear that:

“Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self-harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.”

Links to the Report:

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