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recurance

Mark Harris

17 Jan 2019 · Coroner Jacqueline Devonish · Suffolk

The coroner's concerns

  1. 1. mis-spelt name of the deceased provided to police

    “The 999 call was directed to the ambulance service for a welfare check. The suicide protocol was initiated by the call handler took key information. When the police were called the mis-spelt name of the deceased as HAIS was provided to them together with detail of the nature of the welfare call as 'messaging all night threatening to kill himself.”
  2. 2. unclear police purpose of attendance

    “It was unclear to the police that they were being asked to attend to safeguard ambulance personnel and not to undertake a welfare check. The protocol used by the call handler did not make provision for that to be stated.”
  3. 3. lack of shared information between ambulance and police

    “The police evidence was that in the event of a welfare call, which they could conduct in any event under section 17 powers in the absence of the ambulance service, there was additional information that should be shared including the name and contact telephone number of the informant, and the information recorded in the ambulance service CAD.”
  4. 4. absence of joint communication protocol

    “There is no agreed protocol between the ambulance and police services facilitating communication to formulate an ambulance service protocol which incorporates information helpful to the police.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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