Nobody asked about the warrant

Three police officers stand in the shared lounge of a supported living facility in south London. A man with paranoid schizophrenia, found earlier that night wandering into traffic, has returned indoors and is sitting quietly. The officers believe there is nothing more for them to do here and after just 10 minutes, they leave.

What they didn’t know, and didn’t ask, was that a warrant already existed to take Edward Muwanga into hospital by force. It had been granted four days earlier. The information was sitting in the system, but nobody thought to look for it.

Eight hours later, Muwanga, better known to those close to him as Eddie, was struck and killed by a Central line underground train at Queensway station, having walked there naked and descended onto the tracks just as it pulled in.

A coroner’s Prevention of Future Deaths report, sent to the Commissioner of the Metropolitan Police Service, has now laid out in granular detail how that ten-minute visit went wrong, and why the failures it describes are not really about one bad night, but about what police officers up and down the country are taught to believe their own powers allow them to do.

Section 136 of the Mental Health Act allows police to remove someone from a public place to a place of safety if they appear to be suffering a mental health crisis. The officers who attended Muwanga’s accommodation believed that power simply didn’t apply to him because he was sitting in a lounge inside a private building, not out on the street.

The lounge was shared. Other residents used it. Assistant Coroner Paul Rogers found that this distinction — public versus private, but also communal versus individual — was one the officers got wrong, with consequences that proved fatal.

The coroner’s language about the visit itself was unsparing: “The haste with which they departed – having failed to take reasonable steps to check the status of the warrant – is a noteworthy omission, and indicative of a cavalier attitude to someone in a mental health crisis. A more detailed, measured and thoughtful assessment of Eddie’s situation was warranted.”

No inquiry

Section 135 of the same Act allows a warrant to be obtained compelling a person into hospital assessment. One had been granted for Muwanga on 2 August, after his psychiatric team decided his condition — including a refusal to take medication and a deterioration in his self-care — required intervention. It had not yet been executed.

Staff at his accommodation knew an application had been made. They did not know it had succeeded. When police and paramedics arrived following the 999 call about Muwanga walking into traffic, that gap in knowledge was never closed because nobody on scene asked the question.

The coroner found that two of the three attending officers, the least experienced, did not understand the section 135 process at all. The third, more experienced officer made no inquiry into whether a warrant existed. The coroner noted it was not even clear from the evidence where an officer in that position would go to find out.

With police gone, an ambulance crew assessed Muwanga and sought sign-off from an NHS 111 doctor to leave him at the accommodation overnight. That doctor agreed, partly, the inquest heard, on the understanding that staff would be keeping a close eye on him. The doctor had not seen his full medical notes.

Muwanga left the building unnoticed that night. He arrived at Queensway Underground station naked at around 6.55am, descended to the platform, and climbed onto the tracks as a train entered. The driver applied emergency brakes but could not stop in time.

A jury concluded Muwanga’s death was accidental, finding he had not intended to die. It also found that a delay by Central line controllers in alerting the driver to his presence on the tracks had probably contributed.

The report identifies the Metropolitan Police Commissioner and the College of Policing as the bodies responsible for fixing what went wrong — both for how officers are trained to understand section 136 in communal settings, and for ensuring officers have a clear route to discover whether a section 135 warrant exists for someone they are dealing with.

“I believe the Commissioner of Police for the Metropolis, and the College of Policing are responsible for how officers are trained and educated, and which are the relevant practices and processes for officers to adopt when dealing with persons in mental health crisis in the community as part of their core policing duties,” the coroner wrote.

Revised training

A third concern, sent separately to NHS England and three other health bodies, addresses the fragmented state of patient records that meant neither the ambulance crew nor the NHS 111 doctor could see Muwanga’s full mental health history that night. (A fuller examination of that issue — and what it means for officers attending mental health calls — is covered in our separate article: Out of sight.)

The Metropolitan Police has since acknowledged the failures identified by the coroner. A spokesperson said: “We acknowledge that during a police visit to Edward’s living facility the day before he died, there was a lack of understanding by officers about the powers available to them under the Mental Health Act. We have taken significant steps since to strengthen training and operational practice.”

Those steps include revised training covering sections 135 and 136, specifically incorporating how section 136 powers apply in communal areas. The force has also introduced a warrant recording system accessible to all officers, with a clear expectation that checks will be carried out when attending incidents involving vulnerable individuals. The MPS confirmed it has written to the coroner in response to his report.

This article is a companion piece to our feature Out of sight: why patchy NHS data sharing is now a policing problem