Byline Investigations, in conjunction with the FOIA Centre, publishes key extracts – more than 6,000 words – from the report that the Met did not want you to see on what led to murder by psychiatric patient Nicola Edgington.

Byline Investigates can today reproduce key sections from the official report that reveals how police failures allowed a schizophrenic patient to murder a stranger.

It comes after the Metropolitan Police Service tried to suppress the report of the official investigation into the gruesome murder.

In 2011, Nicola Edgington, who had a history of mental illness and was living in the community, killed Sally Hodkin, a 58-year-old grandmother at random in south-east London.

She slashed her victim’s neck with a butcher’s knife, almost decapitating her.

“She had stabbed her own mother to death in 2005, and the following year was convicted of manslaughter and detained in a secure unit.”

We have read the report in full. It sets out the events of October 10, 2011 that led to murder, and where police and hospital staff fouled up.

Extracts are reproduced exactly below in italics with the same emphasis as in original. Explanatory notes have been added in square brackets.

In the early hours of that morning, Edgington was behaving strangely at a mini-cab office in Greenwich, south-east London…

At 4.01am a mini cab firm contacted the Police to say that Ms Edgington was crying in the back of their office, refusing to leave. At 4.15am two police constables (PCs) arrived, and Ms Edgington informed them that she had mental health issues and needed medication.

It is documented that she was deemed to be agitated, but reasonably compliant in her behaviour. The police constables walked with her out of the office, and she appeared to them to have the self control and capacity to understand what was said to her. They decided to send her to hospital voluntarily, as they genuinely thought she was seeking help. She then refused to get into the ambulance, saying “I’m not getting in that box”.

The PCs did not at any stage carry out a Police National Computer (PNC) check which would have shown that Ms Edgington had a conviction for manslaughter (in 2006 Ms Edgington was convicted of manslaughter after stabbing and fatally injuring her mother. She was detained under section 37/41 of the Mental Health Act (1983) and detained at the Bracton Centre, a Medium Secure Unit, Oxleas NHS Foundation Trust).

The Officers took Ms Edgington to the A&E at Queen Elizabeth Hospital (QEH), they arrived at 4.29am, and helped her to book in. Ms Edgington told the A&E receptionist that she needed to be seen by the mental health team. The officers explained to her that she had to remain there. There were at least 15 people waiting to be seen by the triage nurse at that time.

At 4:31 am, as the Officers were about to leave the car park, Ms Edgington ran out to them. They reassured her, and ushered her back inside at 4:34 am. CCTV footage showed one Officer having a conversation with Ms Edgington by the main entrance. During this time Ms Edgington was seen to move around a lot and appeared to be agitated. Ms Edgington then picked up the direct phone to the taxi company near one of the Officers and said she was going to call a cab. The Officer replied “you don’t have any money”. She then put the phone down and stood near the reception area away from him, once again returning to the direct phone for a taxi in his full view.

At 4:37 am both Officers left the hospital, only to be followed by Ms Edgington again. She reassured the police she was only having a cigarette. Both officers waited for a few minutes and then left to attend to another call.

At 4.37 CCTV footage recorded Ms Edgington entering the hospital by the main entrance by herself, and from this time onwards she is recorded as constantly moving around and appearing agitated. On her return to the A&E waiting area, Ms Edgington asked the receptionist “how long am I going to be here”? and “is it going to take for me to kill someone, as I’ve done it before”.

Edgington asks hospital staff for help and makes a series of telephone calls to the police…

At 4:53 am Ms Edgington was seen by the triage nurse, she said she wanted to see a mental health person and go into hospital. She said everyone wanted to hurt her and she was hearing voices. The psychiatric team accepted her referral.

Whilst waiting to be seen in A&E Ms Edgington called the Police several times, saying that she was dangerous and that she was very scared, and that her Psychiatrist had said that when she was like this she was very dangerous, and also that the last time she felt like this she killed someone.

Ms Edgington also wanted the Police to take her into custody as she felt the hospital staff were not taking her seriously. The Police Communications Officer called the hospital directly, who said that they had the matter in hand.

The Charge Nurse of A&E reported that security came to him saying that there was a lady in the waiting area who was saying that she wanted to kill someone, and she was really distressed and shouting and screaming, and she was shaking and scratching her arms constantly. He called the Mental Health Liaison Nurse (MHLN) and asked him if he knew about the lady. The MHLN did know about her as he had had a referral from the triage nurse. Both the A&E Charge Nurse and the MHLN were unaware of the circumstances preceding her arrival in A&E, and the fact that she had been brought there by police.

At 5:30 am Ms Edgington was seen by the MHLN, who could not access her RiO (electronic) notes whilst assessing her in A&E as the RiO connection was not working properly, however he had looked at her RiO notes in Oxleas House (an acute psychiatric admission unit situated in the grounds of QEH), before he came to assess her.

The MHLN learned from this that she was known to the Bracton Centre and that she had killed her mother. He did not look at the care plan or community crisis plan before coming to assess her. He recorded that she told him that she had been feeling unwell and scared and paranoid.

Ms Edgington reported that she had stopped taking both Sodium Valproate (mood stabiliser) and Quetiapine (anti-psychotic) for months. She talked about flashbacks of being abused as a child, and her concern that her children were being sexually abused in Jamaica. She also stated that she had used Skunk (a form of strong cannabis) recently. She appeared suspicious and wanted the assessment room door left open. The plan made by the MHLN was for Ms Edgington to have an informal admission, and she was placed on level 2 (15 minute) observations while she waited to be escorted to Oxleas House.

Following a discussion with the duty psychiatrist (a GP trainee who had just commenced this post as part of his rotation) the MHLN recorded the plan as: informal admission, with risks to self, harm to others and self neglect being marked “low”, and substance misuse and forensic risk being marked “high” – the latter was said to be “based on the past”. Ms Edgington was placed on level 2 observations – stated within the ‘Safe and Therapeutic Observation Policy (2012)’ as: ‘patients on level two observations should be observed no less frequently than every fifteen minutes’.

The MHLN left the assessment room in A&E and went back to Oxleas House (several minutes’ walk away) to type up his assessment. The Charge Nurse reported to the External Independent Investigation Panel that immediately after he left, Ms Edgington came out of the assessment room and started shouting “when are they taking me to Oxleas, because I’m really unwell I need to be in Oxleas, you people don’t understand”. He further stated that she again ran off, and he and the security guard caught up with her, and together with the Triage Nurse, they got her back to A&E, from where she was then escorted, by a security guard and an A&E Nurse to Oxleas House.

Ms Edgington was initially placed in the Mary Seacole Unit of Oxleas House whilst arrangements were made to admit her. Later Ms Edgington asked if she could wait in the reception area. This was agreed to as she was deemed to be in sight of the night staff.

At 7.05 am Ms Edgington suddenly pushed open the doors to the Unit to leave. She returned but left again at 7.06 am and this time she did not return. Ms Edgington caught a bus to Bexleyheath, where she purchased a knife from a supermarket. Ms Edgington then used the toilet in the supermarket to take the knife out of the wrapper, placing it in her bag.

Ms Edgington then left the supermarket, and went to a bus stop where she attacked and attempted to stab Ms Kerry Clark. Ms Clark successfully fought off Ms Edgington, who dropped the knife. Ms Edgington then grabbed a knife from a butcher’s shop situated near the attack, and ran off to a nearby memorial park, where she encountered and fatally stabbed Mrs Sally Hodkin with the knife. Mrs Hodkin was pronounced dead at the scene.

Under the heading “Contributory factors”, it says…

1. The National Patient Safety Agency (NPSA) determines “contributory factors as those which affect the performance of individuals whose actions may have an effect on the delivery of safe and effective care to Service Users and hence the likelihood of Care Delivery or Service Delivery problems occurring”. Contributory factors may be considered to either influence the occurrence or outcome of an incident, or to actually cause it. The removal of the influence may not always prevent incident recurrence but will generally improve the safety of the care system; whereas the removal of causal factors or ‘root causes’ will be expected to prevent or significantly reduce the chances of reoccurrence”.

2. The Independent Investigation Panel, following application of a Root Cause Analysis approach… concluded that there were fundamental root causes or causal factors for this incident, which will be addressed [below]. There are also several contributory factors which affected the delivery of safe and effective care to Ms Edgington. These are set out under the following headings, as follows:

2.1 Service user

2.2 Involvement of Family members and other Stakeholders

2.3 Clinical assessments

2.1 Service user

1. The Consultant Forensic Psychiatrist who assessed Ms Edgington on behalf of the Bracton Clinic (on 13/12/05) concluded that there was some evidence that Ms Edgington was “suffering from a mental illness as evidenced by her over-valued or delusional ideas in relation to her ex-boyfriend and family members, and the apparent deterioration in her social and occupational functioning in the weeks leading up to the alleged index offence” (in November 2005). He felt she would benefit from a period of assessment in medium security. Despite the prison Inreach Team initially recording no evidence of mental illness, the External Independent Investigation Panel agree that she was appropriately transferred to a medium secure bed at the Bracton Centre in February 2006, under Section 48/49 of the Mental Health Act 1983.

2. The internal inquiry [carried out by Oxleas NHS Foundation Trust] described Ms Edgington’s diagnosis as “schizophrenia with a prominent mood component, complicated by emotionally unstable personality traits and a history of substance misuse”, which is the formulation given by the Bracton Associate Specialist in a report for the solicitors in May 2006. At other times in her records, the diagnosis is variously given as paranoid schizophrenia with a prominent mood component, and schizoaffective disorder. The External Independent Investigation Panel understands that the clinical team’s working diagnosis of Ms Edgington lay between Paranoid Schizophrenia with a strong mood component and Schizoaffective disorder, and that she was not diagnosed with a personality disorder.

3. A mental state examination conducted by a Forensic Psychiatrist preparing a report for the Crown Prosecution Service after she fatally stabbed her mother, indicated that “it is likely that when psychiatrists assessed her in the past… she was able to hide her symptoms for the duration of the assessment interviews”, and concluded that “an acute psychotic episode of schizophrenia was present” and that she also had some “emotionally unstable personality traits”. In conclusion, she recommended that Ms Edgington would require a long period of time in a secure hospital environment for further treatment, risk assessment, and long-term rehabilitation.

4. On the 29 September 2009, after spending 3.5 years in the Bracton Centre, Ms Edgington was conditionally discharged, with MoJ [Ministry of Justice] approval, to the Supported Accommodation Housing Association flat. This was not 24 hour staffed accommodation. The External Investigation Panel note the Psychologist’s comments, that “Edgington is trying to present herself in a good light and may be minimising any psychological difficulties” in order to obtain her conditional discharge, and that she had little insight into the offence and therefore the duration of her treatment, and “is fixated on making fast progress to discharge”.

5. Ms Edgington appeared to improve on Sodium Valproate, which is perhaps reinforced by the fact that when it was later reduced in November 2008, it was noted that “There were some concerns in relation to changes in her mental state during the last few days. Increased impatience, more argumentative, critical of others, less tolerant, mood instability. This may relate to her recent change in medication – reduction of Sodium Valproate by 100mgs last week.”

6. At a CPA [Care Programme Approach] review on 3 March 2010, the Consultant Psychiatrist stated that “any likely early changes in Ms Edgington’s mental health are unlikely to be marked but rather the quality of her interactions may appear less warm or sensitive to the needs of others.” Throughout Ms Edgington’s period of conditional discharge, there was evidence of problems with her interaction with others, including family, neighbours, former and current partners, and people in positions of responsibility in the community, but this seems not to have been adequately considered.

7. When Ms Edgington went to Jamaica, there was no evidence of immediate contact with the MoJ, when concerns arose following Ms Edgington’s husband in Jamaica contacting the team, and the elder child’s social worker. When a report was later submitted to the MoJ by the Social Supervisor on the 22 April she stated that Ms Edgington acknowledged she had drunk two Pernods at a party with her husband, but added, “Her mental state has been stable and she has managed many family and relationship issues with equilibrium,” which does not seem to reflect the situation adequately.

8. When the Consultant Psychiatrist subsequently visited Ms Edgington at home following her return from Jamaica, she recorded in the notes that “There was no evidence that Edgington had threatened her husband referring to a knife”, and appeared to accept Ms Edgington’s account that this incident had occurred several years earlier when she was unwell.

9. The CPN [Community Psychiatric Nurse] was informed by a police officer on 3 August 2010 that an ex partner of Ms Edgington had said that she drank alcohol from time to time, and that her behaviour changed when she did, and further reported an occasion when she was threatening to someone who had jumped a queue at a night club and threatened to pull a knife on them. The care team did not do enough to explore this.

10. In 2011 Ms Edgington’s stress factors increased significantly, given that she believed she had miscarried, and she was receiving threatening messages from her last boyfriend. She also stated that a Bracton male patient was threatening her. At this time, her Sodium Valproate had stopped, following a planned and gradual reduction which commenced on 15 July 2010 because of side effects and because she reported that she might be pregnant. There is no evidence to suggest that the team checked with the GP whether Ms Edgington was pregnant. The Consultant Psychiatrist noted that while Edgington reporting two previous boyfriends were threatening her was potentially concerning, she did not consider there to be any fragility in Edgington’s mental state. This raises the question of whether the care team should have been more alert to the impact of her personality traits and volatile relationships with men, both in relation to putting her at risk of relapse, and in relation to potential risk to others.

11. In June 2011 Ms Edgington was “working three days a week for a security company. Her primary tasks are cold calling.” There does not appear to have been consideration given to gaining her consent to make contact with the employer, or to considering the appropriateness of the job.

12. In September 2011 Ms Edgington again believed that she had had a miscarriage, even though this was not confirmed by the GP. Although she discussed this with the CPN, there does not seem to have been adequate recognition of or response to the significance of this risk factor, or its subsequent relationship to her trying to contact her brother, and telling the Bracton patient – inferring the baby would be his.

13. On Thursday the 6 October 2011 the Social Supervisor wrote about a telephone conversation she had with Ms Edgington after Ms Edgington was not at home for a scheduled appointment. “She said her brother had replied to her in an offensive manner last Wednesday.” The Social Supervisor arranged to meet Ms Edgington on the Monday (October 10) at 5pm.

14. Given the significance of Ms Edgington thinking she had miscarried, trying to contact her brother to tell him this, and the likely impact of his terse reply, in retrospect it is easy to suggest that Ms Edgington should have been seen on 6th or 7th October (before the weekend).

15. If Ms Edgington had been in a 24 hour staffed hostel, it is likely that hostel staff would have been aware of her deterioration over the weekend 7-10th October, given her general behaviour and contact with the Police and this would have afforded more of an opportunity to effect a safe admission to hospital and to communicate directly with duty staff from the Trust to raise their concerns.

16 However even if the significance of these developments was not apparent at the time, had Ms Edgington been in 24 hour staffed accommodation, hostel staff may have been able to effect her safe admission to hospital over the 9 – 10 October.

17. Ms Edgington was exhibiting signs of agitation and distress at the minicab office when the PCs attended, and she also clearly informed the Officers that she had mental health issues and needed medication. When she also refused to get in the ambulance, this should have raised their concerns about the fragility of her mental health and her level of cooperation. The Officers did not carry out a PNC check which would have shown them that she had a conviction for Manslaughter.

2.2 Involvement of Family members and other Stakeholders

1. Both Ms Edgington’s sister and father had contact with her when she was at the Bracton Centre. Her father, sister and brother, in interviews with the External Investigation Panel, felt that they were not consulted, and their views were not considered by the care team. For example, the incident at Christmas when her father visited Ms Edgington [they had a row], and a judgement about what took place was made by the team on the word of Ms Edgington only.

2. As Ms Edgington’s husband lived in Jamaica, Ms Edgington’s father was legally Ms Edgington’s next of kin under the Mental Health Act 1983. There was a missed opportunity for the Bracton team to seek collateral information about Ms Edgington’s history and behaviour from family members.

3. Throughout Ms Edgington’s period of conditional discharge, evidence of problems with her interaction with others, whether it be family, neighbours, previous partners, or people in official positions in the community, seem not to have been adequately considered by the team.

4. There was an invitation to the local mental health team in Greenwich to attend a section 117 aftercare meeting, which was sent a week before the meeting. Their presence was requested for their knowledge of local services, not to provide direct supervision. There was no record found of the local authority Social Services being invited, despite them having an interest in the welfare of Ms Edgington’s children in Jamaica, and they should have been party to the later discussions about Ms Edgington visiting them in Jamaica.

5. It is not clear from the clinical notes which agencies were invited to the Bracton Centre CPA reviews for Ms Edgington. Her GP did not contribute, but had information concerning Ms Edgington’s assumed pregnancies which would have been useful in terms of considering Ms Edgington’s stress levels about pregnancy. The GP practice did not have a record of the relapse indicators. Ms Edgington’s father was not invited to attend, yet he was the legal next of kin, given that her husband was not resident in the UK and therefore was ineligible to exercise the Nearest Relative function. Mr [name removed] also had useful information about Ms Edgington’s concerning behaviour in the community.

6. On 23 June 2011 the CPN recorded that Ms Edgington was “working three days a week for a security company. Her primary tasks are cold calling”. There does not appear to have been consideration about making contact with the employer, or considering the appropriateness of the job.

7. On Saturday evening 8 October, Ms Edgington’s brother phoned the Bracton Centre reception and told them his sister had contacted him and he did not think she was well. Her brother said to the Independent Investigation Panel that he was told if Ms Edgington was bothering him, he should call the Police. This response was inadequate in terms of risk management. If her clinical team had been made aware of this, and it was combined with knowledge of the events of the previous week, there would have been a possibility for intervention, although it was, of course, out of hours.

2.3 Clinical assessments

1. Whilst the External Independent Investigation Panel accepts that applying to the MoJ for a conditional discharge is a legal route open to the clinical team, In the case of Ms Edgington, who was a high profile patient and who by the clinical team’s own account, was challenging when faced with controls placed on her, it seemed to the Independent Investigation Panel that continuing with her application to the First Tier Mental Health Tribunal would have had her stage of readiness and mental health tested by a Tribunal appointed Judge, Independent Consultant Psychiatrist and a lay member.

2. Prior to her discharge from the Bracton Centre, Ms Edgington’s eligibility for MAPPA [Multi-Agency Public Protection Arrangements] was discussed. A MAPPA referral form was completed to send to MAPPA for their decision on her eligibility and level. The referral indicated consideration for level 2/3. The referral did not present a complete picture of Ms Edgington’s history of previous convictions and aggressive behaviour, and was in other respects also, not fully accurate, in that it stated: “Her sister and brother no longer appear to be hostile towards her.”

3. This was an assumption, given that her sister had said that she would not see her in the community without support and Ms Edgington had not seen her brother since before killing their mother.

4. The referral, completed by the Social Supervisor, was sent to the Bracton Centre’s link for MAPPA referrals but was not sent on by the Bracton Coordinator for MAPPA.

5. The Risk, Crisis and Contingency Plan did not reflect all documented risk factors – such as Ms Edgington’s increased stress levels in relation to pregnancy, or her employment.

6. On 16 December 2009 a CPA Management Review was carried out. The CPA documentation or notes of the meeting do not refer to the concerns raised by the tenants at the supported accommodation, or the confrontation with the ticket inspector [she refused to give her name or address to him after he caught her sitting in first class without the right ticket].

7. When Ms Edgington took a part time job as a telephone call sales person, the appropriateness of this role was not questioned as part of her CPA review, or by the care team at any other time. It is documented in the clinical records that Ms Edgington felt she was probably bullying a member of staff at her place of work. Ms Edgington worked three days a week, and this was a missed opportunity to learn more about how she was relating to her peers, and managing the additional stress of work.

8. On 15 January 2009 a Social Circumstances report for the Mental Health Tribunal, notes that Ms Edgington is nervous about moving to an environment where she will be alone at night. The care team considered that Ms Edgington had good self care and was very compliant with medication and treatment, and was prepared to be open with her care team about her needs. For those reasons the decision was made that she should be placed in supported accommodation, rather than a 24 hour staffed hostel or care home.

9. If Ms Edgington had been based in 24 hour supported accommodation following her conditional discharge, there would have been more opportunity to observe her behaviour, in particular her relationships with men.

10. It is documented that the first key worker at Ms Edgington’s accommodation communicated with Ms Edgington’s CPN when the CPN visited Ms Edgington at her flat. However the subsequent key worker reported to the External Independent Investigation that communication was poor, although he reported to the Internal investigation that he had met both the CPN and Social Worker and that they would visit Ms Edgington first and then have a brief word with him.

11. During Ms Edgington’s first trip to Jamaica to see her children, her husband contacted the team saying that Ms Edgington had threatened him with a knife. On her return to England, the Consultant Psychiatrist visited Ms Edgington at home, and wrote the following in the RiO notes “There was no evidence that Ms Edgington had threatened her husband referring to a knife.” This assessment was based on Ms Edgington’s word, there is no evidence that this was corroborated by her husband in Jamaica. Had this report been explored more fully, and the information shared with the MoJ, the possibility of recall could have been considered.

Under the heading “Root Causes/Causal factors”, in the section that led the Met to try to ban publication of the report, and which was altered slightly from the draft as a result, it says…

The NPSA determines a root cause as “a fundamental contributory factor which if removed will be expected to prevent or significantly reduce the chances of reoccurrence”. The Independent Investigation has concluded that there are two fundamental contributory or causal factors as follows:

1. The External Independent Investigation Panel is of the view that there was enough evidence for the police to place Ms Edgington under section 136 of the MHA 1983 on one occasion in the small hours of the 10 October 2011, when she was observed by the Police (as stated in their statements) coming out of A&E for the second time. The PCs recognised that she had mental health problems and although she appeared to be willing to go to hospital, she did in fact leave A&E twice, the first time being escorted back to reception by the Police Officers, after they reassured her and the second time saying that she had only come out for a cigarette. When she came out of hospital a second time the Police had an opportunity to question her willingness to remain. Ms Edgington had used the dedicated taxi phone on two occasions to call a mini-cab in the presence of the PC and had her call terminated by the PC on the second occasion. At this point the Panel felt it would have been reasonable for the PCs to conclude it was necessary to detain her under section 136 of the MHA. In their view, Ms Edgington met both the criteria for section 136 set out in the Policing Mental Health Standard Operating Procedure, February 2011, and the justification of compulsion for willing patients.

The panel accepts that section 136 of the Mental Health Act is an emergency power and that whether to use it is a judgement call. Given this set of circumstances some Police officers may have applied Section 136 of the Mental Health Act whilst others may not have. The Police Officers involved reached their decision in good faith and were satisfied that Ms Edgington did not meet the relevant test. However, the Panel believes that Ms Edgington could have been placed on a section 136 in light of her level of agitation and her demonstration of intention to leave the unit by twice attempting to arrange a taxi via the dedicated free taxi phone in the presence of the police officer. This was followed by Ms Edgington’s leaving of the A&E unit for a second time and it is the view of the Panel that the likelihood of her remaining to undergo voluntary admission had by now been placed in serious doubt. When leaving the QEH the police officers had felt that Ms Edgington “had appeared fine, that she was a little nervous but ultimately was not happy with having to wait to be given her medication”, the accompanying PC stated that “She genuinely seemed as though she wanted help”. Both PC’s stated that the Hospital was where she was repeatedly asking to be. They left the situation therefore feeling that she was nervous but presenting no threat and that she was in a place where she both wanted to be and would receive the support and care that she needed. The panel view is that throughout the period of her interaction with the emergency services Ms Edgington was expressing the view that she wanted treatment and care.

Had Ms Edgington been detained on Section 136 she would have been taken immediately to the locked Section 136 assessment unit within Oxleas House, being the designated safe place. Once there, the Trust standard is that the Duty Psychiatrist should assess the patient within 60 minutes. This assessment would have revealed that Ms Edgington was a conditionally discharged restricted patient with a conviction for manslaughter; this would have allowed a much more considered assessment to take place, with Ms Edgington detained throughout. The circumstances of this case highlight the need for a process by which the police and other emergency services are able to conduct, on arrival, an appropriate handover of the patient with appropriate health professionals regardless of the manner through which crisis mental health care is sought.

2. The MHLN had ascertained before going to A&E that she had killed her mother and was known to the Bracton Centre. However, he did not look at the care plan or crisis plan before going to assess her and was unable to access her electronic records whilst assessing her. He recorded her hearing voices, her request to be sectioned because she did not feel safe, that she had ceased taking all her medication and that she had used a strong form of cannabis. He was unaware that she had been taken to A&E by the police. Her contingency plan in part stated “there should be a low threshold for admission given the seriousness of the index offence…it is also known Edgington was seen by a psychiatrist in the weeks before the offence and not thought to be psychiatrically unwell….this would appear Ms Edgington can mask emerging symptoms of her illness”.

The Panel does acknowledge that he accurately assessed Ms Edgington as needing admission and accurately scored her high as a forensic risk, and that following a discussion with the Duty Doctor at Oxleas House, her observation level was set at level 2 – which is to observe every 15 minutes.

2.1 Given what the nurse knew of the patient and his interview notes this does not seem to the panel an unreasonable judgement. Ms Edgington did not show any signs of wanting to abscond to the nurse. However the panel do believe that had the nurse availed himself of the full information available then a different outcome may have resulted.

2.2 If the nurse had read the balance of paperwork that was not read, would it have made any difference to that assessment of presentation?

The balance of the paperwork available to the MHLN included the Care Plan and the Community Crisis Plan. These documents would have informed him that: she was stated to require a low threshold for admission; that she could mask the signs of her psychiatric illness; and emergency acute admission should be facilitated via home treatment team or via presentation at Oxleas House.

Given this additional information the panel believes that the correct level of observation should have been one to one constant observation.

2.3 If Ms Edgington had been observed constantly by a nurse following her arrival at A&E, would her presentation have led to 1:1 observation?

An observer of Ms Edgington following her arrival at the A&E department would have been witness to:

· Her arriving under police escort

· Her agitation and distressed behaviour

· Her leaving the department on several occasions

· Her attempting to phone for taxis to take her away

· Her threats to kill

· Shouting, disruptive and abusive language

· Phone calls to the police (999)

· Her fear of being in the unit

· Her wanting someone to be with her

Given this presentation the panel believe that it would have significantly raised the risk profile for Ms Edgington and that one to one observation levels would have been indicated.

2.4 If Ms Edgington had been observed constantly and had the balance of her clinical notes read would this have changed the observation level?

Given the above the panel believe that the additional written information and observations of her behaviour following arrival at the A&E unit would have significantly raised the risk profile for Ms Edgington and that one to one observation levels would have been indicated.

Whilst the External Independent Panel accept that this was a judgement made by the MHLN and the Duty Doctor, they judge the observation level to be inadequate given her forensic history and clinical presentation. Had Ms Edgington’s observation levels been set so that she was in eyesight at all times (as indicated by her forensic history and clinical presentation at that time) then this would have provided an opportunity to support Ms Edgington and discourage her from leaving before being admitted to the in patient service.

Once Ms Edgington was escorted to Oxleas House it would have become obvious to anyone observing her that Ms Edgington was not settled, she asked to sit in a reception area where she could see staff and she pushed open the inner and outer doors of Oxleas house and then went back into the Unit, before absconding one minute later. Had Ms Edgington been on eyesight observation there would have been, as described in the Trust Policy, an opportunity to engage with Ms Edgington whilst continuing to clinically assess her. There would also have been an opportunity to persuade her from leaving Oxleas house by the observing staff member. This observation level assessment and the consequent poor follow up within Oxleas House, gave Ms Edgington the opportunity to leave Oxleas House without challenge.

The report identifies a series of “service delivery problems” in the care and treatment of Edgington…

1 Correspondence to the Ministry of Justice (MoJ) did not fully reflect Ms Edgington’s behaviour and presentation, and in one particular instance, the MoJ request to inform immediately if concerns arose during a trip to Jamaica, was not followed.

2 Communication between the A&E Department and the MHLN did not ensure that important elements of Ms Edgington’s presentation were understood by all.

3 The Admission Care Pathway and the Mental Health Liaison Policy differ on who escorts patients from A&E to OH [Oxleas House].

4 The care team did not provide full information on the referral form to MAPPA and, following Ms Edgington’s discharge there is no evidence they discussed MAPPA involvement.

5 There is no document setting standards for those who will be in receipt of Section 117 after care who are being discharged and followed up by the forensic service.

It also identifies a series of “care delivery problems in Edgington’s treatment…

1 There was a failure to gain a view of family members involved in specific situations with Ms Edgington. The care team were too ready to accept Ms Edgington’s account of potentially worrying situations, and not enough weight was given to alternative accounts, or no attempt was made to get the views of family members involved.

2 Ms Edgington’s potential risk of violence to others in the community was not adequately considered by her care team, particularly on occasions when there were worrying reports about her behaviour, and/or stresses to which she was subject.

3 There was no overview of Ms Edgington’s presentation and changing level of risk when experiencing stresses which were identified in her care plan as associated with relapse. The care team responded on a reactive basis to issues as they occurred, and did not adequately consider the overall impact of these events on Ms Edgington’s mental state and behaviour, and her level of risk to others.

4 There was no communication with Ms Edgington’s employers. The Panel recognises that the team would have had to ask Ms Edgington’s permission to talk to her employers, and if refused, to have decided if they were justified in breaching her confidentiality. However the panel considers that these issues should have been discussed by the team. Ms Edgington remained a conditionally discharged restricted patient.

5 There was telephone contact only on 6 October 2011 after Ms Edgington missed her appointment. The panel considers that there should have been a review of Ms Edgington before the weekend, when it was clear that she was subject to several significant stresses, had engaged in uncharacteristic behaviour and believed that she had miscarried, even though this was not true.

6 CPA reviews did not refer to all the key people who could have provided useful information regarding Ms Edgington’s behaviour and presentation.

7 Patients should feel closely supported in the community, and the care team can ensure that the patient’s presenting behaviour is kept under closer scrutiny. The practice of placing conditionally discharged patients in low support accommodation should be reviewed.

Among its recommendations, the report says that the Oxleas NHS Foundation Trust “should satisfy itself” that it is acceptable for a consultant psychiatrist to apply to the Ministry of Justice for a conditional discharge from the Bracton Centre, rather than the patient seeking this at the mental health tribunal.

It recommends a review of the Bracton Centre’s communications with the Ministry of Justice because “correspondence to the MoJ did not fully reflect Ms Edgington’s behaviour and presentation.”

And the report says: “The circumstances of this case highlight the need for a process by which the police and other emergency services are able to conduct, on arrival, an appropriate handover of the patient with appropriate health professionals regardless of the manner through which crisis mental health care is sought.”

COMING SOONmore revelations about how the Met covered up conclusions about police failures that led to murder of grandmother Sally Hodkin.