Police sent urgent request to neighbouring force to find high-risk missing person by email, instead of phone
James Chrismas called 999 at 16:34 on 18th October 2021 after receiving text messages from his wife – Meghan Irene Chrismas – stating that she was going to hang herself. Hampshire Police immediately graded Meghan as a Grade 1 missing person, and an officer was dispatched to the family home.
The initial police investigations quickly discovered that Meghan was at the Premier Inn in Guilford, Surrey. A decision was made not to deploy Hampshire officers to the hotel, but to request that Surrey Police attend instead. This request was made at 17:18. However, due to some confusion regarding Meghan’s risk status, that communication was made by email instead of by telephone. The jury found that this was “inappropriate in light of the reality of the incident”. Unfortunately, as the email inbox was for non-urgent enquiries, the email was not picked up by Surrey Police.
There was then a delay of around one hour – until 18:15 – before Hampshire police eventually called Surrey police for an update, and realised that the email had not been seen. At this point, Surrey quickly deployed officers to the Premier Inn. Unfortunately, when they arrived at the hotel, Meghan had was unconscious, having already attempted to take her own life by ligature.
The last message that Meghan sent to her family was at 18:19, and the evidence from Surrey Police was that, had they been called at 17:18 when the email was sent, the timings of their deployment would have been the same i.e., they would have arrived at the hotel within around 20 minutes. They would therefore have arrived before Meghan had ligatured.
Whilst the officers did manage to resuscitate Meghan, she had already suffered a hypoxic brain injury, and died at the Royal Surrey County Hospital (RSCH) two days later on 20th October 2021.
Meghan had suffered a deterioration in her mental health in July 2021, after she experienced a panic attack and was admitted to the Priory Hospital, Roehampton, as a voluntary inpatient. She was diagnosed with Generalised Anxiety Disorder, Depression, ADHD and Complex PTSD, and prescribed various medications. She continued to receive outpatient treatment from a private consultant psychiatrist, as well as an Eye Movement Desensitisation and Reprocessing (EMDR) therapy. The jury found that Meghan had been receiving prescriptions from both her private consultant and her GP, meaning that she had access to double her prescribed medication.
On 1st October 2021, Meghan had impulsively tried to take her own life with an overdose of her prescribed medication. She was admitted to RSCH and discharged the next day. Whilst her GP received a letter from psychiatric liaison about Meghan’s attempted suicide and hospital admission, this was not passed on to her private psychiatrist or EMDR therapist and they did not find out about this until after she died. By 12th October 2021, James had become extremely concerned about Meghan’s mental health and requested that her GP make an urgent referral to the local NHS mental health services, which he agreed to do. Unfortunately, this was rejected as Meghan had not consented to be referred.
The Coroner has listed a further hearing to address Prevention of Future Deaths issues. He has expressed particular concerns about: (1) the passage of information between NHS and private healthcare providers; and (2) the handling of the incident in the Hampshire control room, which resulted in the hour delay in determining that the communication had not been received by Surrey.
The family was represented by Matthew Turner instructed by Mollie Eglesfield and Farheen Ahmed of GT Stewart Solicitors.
The Coroner was HM Assistant Coroner for Surrey, Darren Stewart OBE.
The other Interested Persons were the Hampshire Constabulary, Surrey Police, the Priory Group, Surrey and Borders Partnership NHS Foundation Trust (SABP), Meghan’s private consultant psychiatrist, Meghan’s GP, and a Hampshire police control centre employee.
