An inquest jury have concluded that Robert’s death was by suicide, and they criticised several aspects of the emergency services response.

Robert, known as Rob, was described by his family as “a very happy person, who was always smiling, even when life got hard. He was extremely easy to like. He made a positive impact on everyone he met. He loved making others smile.” He died on 30 January 2022, at the age of 42. His inquest was heard at Sandwell & Dudley Coroner’s Court between 08 – 16 April 2024 before HM Senior Coroner Zafar Siddique.

Rob had suffered with his mental health for a number of years and was diagnosed with depression and anxiety.

In the early hours of 30 January 2022, Rob made two calls to the emergency services. During the call with the police, Rob stated that he did not want “to be resuscitated” and suggested that he no longer wanted to live. During the call, Rob was very upset and crying, and refused to answer when the call operator asked if he was going to do anything silly. Shortly after, Rob cleared the line. That call was graded as Priority 1, which attracts a 15-minute response time by police, and officers were dispatched to the scene at 03:35am.

Rob was also contacted by ambulance services, and Rob stated that he didn’t ‘want to be brought back to life’. The ambulance call taker asked if Rob needed an ambulance, to which he responded, ‘no’ and said ‘do not resuscitate me I don’t want to live’. The ambulance call taker responded, ‘If anything gets worse or changes call us back’, and the log was subsequently closed.

The police officer who was tasked to respond to the Priority 1 call, determined that this was a matter better suited for ambulance, and stated it did not need a police response. The police dispatcher disagreed and escalated the matter to a supervisor. However, the police officer was dispatched to another incident before the case could be reviewed by the duty sergeant. By the time the decision was reviewed, no other police resources were available to respond to the incident.

Ambulance services were contacted by police and asked to respond to the incident. During that call, ambulance services were informed that police had been asked to attend the incident. A further call to ambulance services did not specify that police would not be attending the incident, but did state that police needed to ‘pass’ ambulance a job. Police witnesses, including a dispatcher and the former Head of Contact Handling, gave evidence that this meant that police wanted ambulance services to attend the incident but would no longer be attending themselves. Ambulance witnesses, including a call handler and the Integrated Emergency Urgent Care & Performance Director, gave evidence that there was no such shared language between the two services and that the words ‘pass a job’ were used on a daily basis in communication between the services but did not convey that police would not be attending the scene.

When paramedics arrived at the scene at approximately 03:56am, 36 minutes after Rob’s initial call to emergency services, they were unable to gain entry to the property and were expecting police attendance. Paramedics requested an update on the arrival time of police, but only learned at approximately 04:05am that police had taken the decision not to attend the scene. Upon looking through Rob’s letter box, paramedics saw Rob and identified that he required urgent medical attention. Paramedics kicked down the door to the property at 04:07am and started resuscitation attempts, but Rob was sadly pronounced deceased at 04:47am.

Forensic analysis of Rob’s phone revealed that he sent a Facebook message to his son at 04:04am, just minutes before paramedics gained entry to Rob’s address.

The jury made the following findings in respect of the response by emergency services:

• Inadequate information about Rob’s identity was gained from the initial 999 call between Rob and the police call handler, meaning that Rob’s history of suicide attempts was not recorded on the police log relating to the incident.
• The release of the police officers from the incident involving Rob and dispatch of those officers to another incident before a supervisor had reviewed the decision was inappropriate.
• A difference of ‘interpretation and understanding between police and ambulance services’ regarding what it means to ‘pass’ a job to ambulance services led to confusion about whether police would be attending the incident involving Rob.
• The initial call back from ambulance services to Rob was inadequate as it failed to identify any personal details of the caller, therefore the ambulance incident log was closed without further action requested from ambulance services.

Rob’s family were represented by Lucie Boase and Nicola Miller of Broudie Jackson Canter Solicitors, and Ruby Peacock of Doughty Street Chambers. Commenting on the inquest conclusion, Nicola Miller said:

Following Rob’s death and the evidence heard at the inquest, the emergency services confirmed that they had made changes to their policies and procedures in the hope of preventing another death like Rob’s. Finally, Rob’s family have the answers to some of their questions as to what happened on 30 January 2022, and they hope that lessons have been learnt to prevent this tragedy happening to any other family.

Rob’s younger sister Zara said:

We are relieved that Rob’s inquest has now concluded, and we hope that the changes made by the emergency services will help to provide better responses to those suffering from mental health crises. Rob was an amazing son, brother, father and friend, and his passing has left a massive hole in the lives of all who knew him. We miss Rob every day and will forever cherish the memories we have with him.