Surrey woman's 'avoidable' death was 'contributed to by neglect' as coroner calls for police to share information out of hours

Helen Kerr was found dead in her sheltered accommodation in Woking on April 3, 2023, after attending the police station and being admitted to hospital with “extreme paranoia” and psychosis.

Surrey coroner, Caroline Topping, said Ms Kerr’s death was “contributed to by neglect” and was “avoidable with appropriate treatment” like antipsychotic medication.

A risk assessment form raising concerns about Ms Kerr’s vulnerability was not processed until after Ms Kerr’s death. A Single Combined Assessment and Risk Form (SCARF) is shared with other agencies, like mental health services or adult safeguarding, to assess the level of risk and work out the next steps.

Surrey Police filed a SCARF risk assessment form at the end of the working day on Friday March 31. But the form was not processed until after the weekend, on Monday the April 3rd. The Coroner said the SCARF system does not enable information sharing between the police, mental health agencies and adult safeguarding out of hours.

Although the SCARF process is under review, Coroner Topping said it is “unclear” how sharing information outside of working hours is to be done in a timely way to “safeguard individuals and the public”.

Despite information about Ms Kerr’s declining mental health being provided to Surrey and Borders Partnership (SABP) from support workers, she was not given timely treatment.

Coroner Topping said information about Ms Kerr’s mental health was “not explored” and “insufficient weight” was given to it during her triage process.

Ms Kerr, who had a history of drug and alcohol abuse, was placed in a refuge in Woking on February 2. According to the report, Ms Kerr’s mental health deteriorated and she developed psychosis. She was assessed by SABP on March 1, but because of work pressures, Ms Kerr was not referred to the community health team despite a plan being in place.

When she was taken to hospital a fortnight later (March 13) by her concerned support worker, no information about her mental health was sought from personal contacts and the paramedic’s description of her case was also not read. She was seen by a nurse from the liaison psychiatry team but was discharged despite showing signs of paranoid delusions.

Although SABP provided evidence to show it has changed procedures to process referrals into services, the coroner said she still remains concerned. SABP said referrals can be made by voluntary agencies, triaging decisions now have more senior oversight and information from contacts is not recorded for referrals.

“SABP NHS Foundation Trust Chief Executive, Graham Wareham said: “I am deeply saddened by the tragic death of Helen Kerr and have written to her family to express my sincere apologies for the shortcomings in her care. We made a commitment to making improvements in response to concerns raised during the inquest and can confirm the following changes have been put in place.”

Mr Wareham said SABP has adopted the Right Care Right Person model in partnership with Surrey Police which provides a framework for assisting police with their decision-making when responding to reported incidents involving people with mental health needs.

The organisation has extended the professionals’ line for emergency and urgent referrals to a wider group, including third sector organisations and accommodation providers. The NHS Trust has also reduced the time taken to follow up on urgent referrals from five days to 48 hours, with emergency referrals continue to be followed up within 24 hours. SABP said it will continue to take on board any further feedback from the Coroner.”

Ms Kerr attended Surrey Police station in “an extremely psychotic and paranoid state” on March 31. She was having “paranoid delusions” about the actions of the refuge workers and was concerned for her own safety. The court was told that GDPR prevented the police from sharing the information about Ms Kerr with the centre. But the coroner concluded that Ms Kerr’s delusions “could have put the refuge staff in danger”.

Prior to being placed in a refuge sanctuary, Surrey Police records show Ms Kerr had been arrested and charged with carrying a blade which she said she was carrying a knife for her own protection. Police were also called to the centre by paramedics as they were concerned Ms Kerr was carrying a nail file “for her own protection”.

An expert also gave evidence that she would have been “very worried” if she was told Ms Kerr was carrying a knife because she was having paranoid delusions about needing to protect herself and her family.

The officer who saw Ms Kerr could not leave the interview room to read her files because of her condition. Although she was “extremely paranoid”, the police assessed that she did not need to be detained under the Mental Health Act. But Surrey Police did not assess the potential risk Ms Kerr’s condition posed to the public and so no action was taken, according to the report.

A spokesperson for Surrey Police said: “We have received a copy of the Preventing Future Deaths report published last week and are carefully considering the concerns raised around information sharing. The Force will be responding to the Coroner in due course.”

Prevention of Future Death Report: https://www.judiciary.uk/prevention-of-future-death-reports/helen-kerr-prevention-of-future-deaths-report/