- The dispatcher noted on the call log that the patient wanted to die,
- but this particular piece of information was not conveyed.
- The information which the crew were given was:
- Psychiatric/Abnormal behaviour/
- Suicide attempt;
- trying to slit wrists; Armed with a weapon –
- glass.
- Therefore
- the crew were given adequate information
- of the patient’s intent.
- She was due to attend the Jobcentre on the fourth
- to make her declaration of unemployment
- in order to remain eligible for her benefit payment.
- However, she contacted the centre that day
- to say she was sick.
- She subsequently attended on the seventh
- where she explained that she had not come in on the fourth
- because she was ill.
- She was asked to complete a form
- to formally declare her sickness.
- She completed and returned the form,
- then immediately left.
- This meant that the Work Coach
- was unable to discuss
- the details of the statement she had made:
- ‘I was busy trying to kill myself,
- drinking non-stop.’
- There is a space on the form
- for the date when you started being unwell
- (she put the fourth)
- and another
- for when you think you will be well again
- (she put the seventh).
- The coach discussed his concerns with his line manager, and
- recorded the incident
- in accordance with Department procedures.
- Policies state
- that employees are empowered
- to take any reasonable steps,
- including contacting the emergency services,
- if they feel the customer
- faces clear and significant risks to their welfare
- or safety. In this case,
- based on the information he had,
- the Work Coach made a judgement
- that there was no immediate risk to the customer’s safety.
- She died later that same day.
- On the morning of the sixth,
- she reported that a man had attempted to rape her in her home.
- One of the first-responding officers,
- on encountering her outside her address,
- noticed blood on her clothing, and,
- quite properly,
- attempted to persuade her
- to allow police to seize the clothing
- for forensic examination,
- and to dissuade her from immediately returning to her home,
- the apparent crime scene.
- A third party witness
- expressed surprise at the intrusiveness of the questioning,
- conducted by a male officer
- in a public area;
- a less than ideal situation.
- The witness added that,
- although the officers’ questions were not in any way inappropriate,
- and they had explained why they needed to ask them,
- she would herself have felt
- uncomfortable
- answering such questions
- in such a way.
- The second attending officer sought advice
- from the Team Detective Sergeant
- regarding how best to proceed with the agitated woman
- who informed the officers that she had been
- drinking throughout the preceding night. In line with best practice
- a female Sexual Offences Investigation Trained (SOIT) officer
- was tasked to attend.
- Despite difficulties,
- officers obtained
- sufficient detail
- to circulate a description of the suspect,
- who was promptly arrested nearby.
- (He was later released.)
- It was clear that there was some tension
- between the desire on the part of the initial attending officers
- to achieve best evidence
- and the manner and location of the communication
- between the woman and those officers,
- necessitated by the character of contact
- between the parties.
- She walked off towards her flat;
- an officer followed
- trying to prevent her from entering.
- Once outside the address he and another officer
- tried to explain to her
- why the scene needed to be preserved
- but she continued to be obstructive.
- She continued to demand that she be allowed to enter her flat
- and threatened
- to kick her own door down. Eventually
- she used her keys to enter the address
- and closed the door.
- Research indicated she was capable
- of being volatile and violent
- when intoxicated.
- Reports for example
- indicated she had assaulted police in her home
- five months earlier
- when they attended there
- to check on her welfare.
- The Detective Sergeant
- decided that
- in her present state of mind
- she was no longer suitable
- for an immediate SOIT officer deployment,
- and instead arranged for an officer
- to re-attend the address
- with a colleague
- the following day,
- which was the seventh.
- On arrival
- the front door was closed.
- The officer knocked several times
- before a female voice from within said ‘Who
- is it?’
- It’s the police. Can you open the door please?
- The voice
- replied ‘Everything
- is fine. There is
- no crime here.’
- Can you open the door?
- I don’t want to force it open.
- We just need to speak to you
- that’s all.
- The door was opened.
- She said
- ‘I don’t need
- you lot. You can
- fuck off.’
- The officer explained
- they were asked to attend
- on behalf of the ambulance service
- as they had been contacted
- by someone threatening
- to harm themselves
- with a piece of broken glass.
- ‘Well it’s not me. I don’t need
- you lot here. I
- never asked you
- to come so can
- you please fuck
- off.’
- Have you hurt yourself with some glass?
- She replied
- ‘No.’
- What’s your name?
- ‘You don’t need
- to know my
- name it’s all
- on your systems.’
- The officer stated he saw a letter
- and a bank card
- on the sofa
- which confirmed her name.
- He said
- Have you called for an ambulance?
- She replied
- ‘No. I don’t need
- an ambulance and I don’t know
- why
- you are here.’
- Could anybody else
- have called an ambulance for you?
- Have you phoned a friend or
- anybody to say
- you were going to hurt yourself
- with some glass?
- She replied
- ‘No. Look
- I never
- called
- you lot
- please
- fuck
- off.’
- The ambulance crew arrived,
- and took over the lead in continuing attempts
- to rapport-build,
- only to experience
- similar difficulties.
- It was during this period that the SOIT officer and a colleague arrived
- having postponed their initial visit
- from the previous day, the sixth.
- No officer present briefed the ambulance crew
- regarding the alleged sexual assault.
- On this occasion too, having been briefed by the first officer
- on the woman’s state of mind
- and volatility,
- and by the ambulance crew
- regarding her
- nevertheless
- evident mental capacity
- and lack of immediate welfare concerns,
- all parties decided
- once again
- to leave.
- About forty minutes later, she left her home.
- She is seen on CCTV entering the station.
- The train was not driver-operated.
- It was travelling at only 15 miles per hour.
- It happened so quickly, commuters
- continued reading their papers.
- They had no idea
- what she was doing.
- The proximate cause of death was injuries sustained
- when she stepped in front of the train.
[Responses from the Metropolitan Police (17/03/2016), London Ambulance Service (11/03/2016) and the DWP (undated) to the Prevention of Future Deaths report made by Coroner ME Hassell, 20/1/2016; added details from The Guardian, 06/02/2016, Faiza Ahmed: how one woman’s cries for help were missed by every authority]