Jury finds inadequate police station mental health assessment and safety planning contributed to the death of Alan Trinder
Alan Trinder, died on 27 August 2020 following a collision with an HGV, having parked his car before walking into the southbound carriageway of the M1 near Gilmorton, Leicestershire.
Mr Trinder was 55 years of age and had been diagnosed with Unspecified Non-Organic Psychosis, following a First Episode of Psychosis in May 2019 following an act of serious self-harm after which he was admitted to hospital under s.2 of the MHA 1983.
Alan had been caught up in an incident with local drug dealers being chased by the Police near his home after which he experienced an onset of paranoia and suicidal thoughts.
He was prescribed anti-psychotic medication – olanzapine - and upon discharge was committed to the care of relevant mental health services for a period of three years.
Alan ceased taking his medication in July 2020 but then initiated contact with his mental health team on 25 August 2020, voicing concern about his mental state. The re-starting of medication and warning signs of relapse were discussed.
On the morning of 26 August 2020 he suddenly and without warning drove off in his car whilst about to embark on a walk with his wife and their dog.
He was known to have returned home telling neighbours he was headed to the Leicester area and it transpired that he had taken a large kitchen knife with him.
After calling the mental health team, Alan’s wife reported him as missing to Thames Valley Police. He was categorized as a high-risk missing person and information was thereafter passed to Leicestershire Police.
Alan was found by in Leicestershire on the morning of 27 August 2020 and was taken to Euston Street Police Station in Leicester.
Concerns were raised by the Custody Sargeant as to Alan’s mental health, and detention was declined. He then underwent a mental health assessment after which he was deemed to have capacity with no necessary admission to hospital and was thereafter voluntarily interviewed by the Police in respect of a suspected offence of possession of a bladed article.
Whilst it was agreed between the mental health practitioner and the Police that Alan was to be escorted home, this was predicated on the basis that Alan would agree to be so escorted, without a contingency/alternative plan being formulated.
Alan subsequently left the Police station, finding his way to the place of his death within half an hour.
The inquest explored the role of the local mental health triage car, consideration of use of s.136 MHA 1983 by the Police, core/risk assessments by a mental health practitioner and the nature of plans to safeguard Alan.
A jury in the Leicester City and South Leicestershire Coroner’s court directed by His Majesty’s Assistant Coroner Susan Evans heard evidence over six days and concluded that Alan died way of suicide following a potential relapse of his mental health illness.
The jury also found that the mental health assessment was not adequately performed with a lack of detailed exploration of on-going or historical events and lack of thorough pre-assessment.
Furthermore, there was a failure to implement a safety plan, in the event that Alan chose to leave the Police station of his own accord. The lack of a safety plan, collaboration with third parties, exploration of a potential relapse as well as a consideration and management of risk plans were found to have more than minimally contributed to Alan’s death.