Learning from Experience Database - Serious Case Reviews

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Case 04 (Worcestershire)

04, was a female Lithuanian national, who had been living and working in the area since May 2010. At around 10:00 on Thursday, 23rd September, 04 was found asleep in the gardens of a public house in Worcestershire. Staff from the public house observed her for several hours but when roused it was evident that she was drunk, and about 14:00 they called an ambulance. She refused to be medically examined and talked about jumping in the river. The police were then called to the scene as 04 appeared to be still suffering from the effects of alcohol. She told the officer that she wanted to kill herself. She had facial injuries, which she then attributed to a road traffic accident a few days previously.  The Police decided to detain 04, under Section 136 of the Mental Health Act 1983, (amended 2007), at 14:45 and she was taken to the Police Station, as a place of safety. She was seen by the Force Medical Examiner who contacted the on-call Approved Mental Health Practitioner. It was agreed later that evening that an assessment was not required and that the Police should discharge her if they had no further concerns when she was sober the next day. 04 was discharged from Custody at about 09:00 on the morning of the 24th September when she was deemed sober and rational. She was released and directed to the railway station as she stated that she wished to visit friends in London. Later that afternoon she was seen on CCTV recordings wandering around the railway station, drinking from a bottle, for about 2 ½ hours. She was asked to leave the station and was escorted from the premises, as she was intoxicated. Shortly afterwards she was seen on the CCTV images entering the Ladies Toilets at the Station and 15 minutes later was found hanging by the neck inside a toilet cubicle. Despite attempts to resuscitate her she was pronounced dead at the scene.

Professional learning:

  • All relevant professionals must be aware of their duty to undertake a Mental Health Assessment of all persons detained under the Section 136 of the Mental Health Act 1983, (amended 2007), in line with the Mental Health Act Code of Practice. Individual professional responsibilities following the discharge of the Section 136 should be clarified and actions recorded.
  • Decision making and actions related to the section 136 process must be clearly documented.
  • Community Safety should work with partners to produce an information pack or booklet initially for transient workers in local employment. Such a pack would be given to them on commencement of their employment and would include details such as how to register with a GP and other local services and information.

2011 November Serious Case Review regarding 04 (Worcestershire)