A coroner has issued an urgent report to the Metropolitan Police after concluding that an 'overly rigid' application of national protocols delayed the search for a missing Lewisham woman, contributing to her death. Catherine Morgan, 37, died on September 4, 2024, after falling from a height in Kent, following her disappearance from Lewisham Hospital.
Inquest findings highlight systemic failures
Senior Coroner Patricia Harding, for Kent and Medway, found that the Met Police's application of the College of Policing's Right Care Right Person policy and Affinity Protocol was 'overly rigid', leading to a delay of more than three and a half hours in deploying officers. An inquest jury determined this delay may have contributed to Catherine's death.
The jury also identified other policing failures, including the untimely categorisation of Catherine as high risk, failure to utilise existing information in Computer-Aided Dispatch (CAD) records, lack of inspector cover during a senior leadership meeting, and absence of a prioritisation policy. These failures collectively hindered the investigation.
Timeline of events on September 4, 2024
Catherine was admitted as a voluntary patient at Lewisham Hospital, part of South London and Maudsley (SLaM) NHS Foundation Trust, after a previous suicide attempt on August 27, 2024. On September 4, she left the ward at 10:30am on unescorted leave, due back by midday. Her absence was only noticed at 12:50pm when her mother arrived for lunch.
Ward staff reported her missing to the Met Police at 1:17pm, but the force declined to investigate, citing the Right Care Right Person policy and Affinity Protocol, and because her registered home address had not been visited. At 1:28pm, her father called police, referencing the earlier suicide attempt, but still no action was taken. Further calls at 2:02pm and 3:39pm were made, yet officers were not deployed until 5pm, when the case was finally graded as high risk.
At 6:59pm, cell site data located Catherine in Kent. Emergency services arrived shortly after, and Kent Police were dispatched at 7:13pm, arriving at 7:47pm. Catherine took her own life at 8:16pm.
Coroner's concerns about police and NHS trust
In her prevention of future deaths report, published on July 28, Ms Harding raised concerns about both the Met Police and SLaM. She noted that SLaM failed to conduct risk assessments in line with NICE guidelines. The inquest jury also found that unescorted leave was not signed out by a registered mental health nurse, the nurse in charge was unaware of the leave, ward staff were unaware of her absence, and a general observation sheet was incorrectly recorded.
Ms Harding highlighted that the Met's 'overly rigid' approach removed call handlers' discretion, and that a call handler's concerns about immediate deployment were overruled by supervisors. She also expressed concern that a call handler advised the NHS Trust to request a welfare check from London Ambulance Service, which only attends if the resident is known to be at the address.
Responses from authorities
A Met Police spokesperson said: 'Our thoughts remain firmly with Catherine’s family and loved ones following their tragic loss. We have received the coroner’s findings contained in the prevention of future deaths report and are committed to learning from these to protect vulnerable people alongside our partner agencies.'
The Met has provided a written response to the coroner, outlining plans to review training on the Right Care Right Person policy and to provide greater support and oversight for staff making decisions involving vulnerable people. They have also established Local Missing Hubs to improve responses to missing person cases.
Vanessa Smith, Chief Nursing Officer of SLaM, said: 'We would like to once again offer our sincere apologies to Catherine's family for the shortcomings identified in her care, and to share our deepest condolences for their loss. We accept the concerns raised by the coroner and have already made significant changes as a result of the learning from Catherine's death, including moving to a more personalised approach to risk assessment in line with NICE guidance.'
Chief Constable Sir Andy Marsh of the College of Policing, in a letter dated July 15, acknowledged the concern that the Right Care Right Person approach 'may be interpreted in a way that restricts the professional judgement of call handlers and despatches resulting in delayed deployment in circumstances involving vulnerable individuals.' He stated that the College is reviewing the national toolkit guidance.
