Coroner warns Met Police after Lewisham woman's death linked to delayed response
Catherine Morgan, 37, took her own life in Kent after police failed to act for over three hours
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The Metropolitan Police’s failure to act for more than three hours after Catherine Morgan was reported missing may have contributed to her death, a coroner has concluded. Morgan, 37, took her own life in Kent on 4 September 2024 after leaving Lewisham Hospital on unescorted leave earlier that day.
Patricia Harding, Senior Coroner for Kent and Medway, wrote an urgent report to the Met Police on 28 July, warning that its policies were applied in an "overly rigid" manner. The inquest jury found that the delay in deploying officers reduced the chances of finding Morgan alive.
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Policy led to critical delays
Morgan was admitted to Lewisham Hospital as a voluntary patient on 27 August 2024 after a previous suicide attempt. On 4 September, she left the ward at 10:30 am on unescorted leave, with an agreement to return by midday. When she failed to return, staff only realised at 12:50 pm, after her mother arrived for a scheduled lunch visit.
Ward staff reported Morgan missing to the Met Police at 1:17 pm. The force declined to investigate, citing the Right Care Right Person policy and the Affinity Protocol. Police said they would not act because Morgan’s registered home address had not been checked. Her father called the police at 1:28 pm, referencing her earlier suicide attempt and confirming she would not return to her flat. The Met still did not launch a search.
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The case was passed between borough command units before being reassigned to South East London at 2:26 pm. Despite being categorised as high risk, no immediate action was taken. The operations inspector, covering for an absent colleague, did not review the case. When the afternoon inspector arrived, she went straight into a meeting without assessing the situation.
Morgan’s father called the Met again at 3:39 pm to report no progress. At 4:02 pm, the operations inspector finally reviewed the case and began enquiries. The Missing Persons Unit only started investigating at 5:00 pm, over three and a half hours after the initial report. By 6:59 pm, phone data located Morgan in Kent. Emergency services arrived shortly after, but she died at 8:16 pm.
Failings by police and NHS trust
The coroner’s report highlighted multiple failures by both the Met Police and South London and Maudsley NHS Foundation Trust (SLaM). Harding said the Met’s rigid application of its policies removed any opportunity for call handlers to use their judgement. A call handler had raised concerns about the need for immediate deployment but was overruled by supervisors.
The inquest also found that SLaM did not follow National Institute for Health and Care Excellence (NICE) guidelines for risk assessments. Unescorted leave was not properly recorded, and ward staff were unaware Morgan had been granted leave. The nurse in charge was not informed, and hourly checks failed to detect her absence until her mother arrived.
The system for monitoring leave was inadequate, reliance being placed on hourly checks. The nurse conducting the hourly check at 12 pm when Catherine was due to return was not aware that she was on unescorted leave.
Patricia Harding, Senior Coroner for Kent and Medway
What happens next
The coroner’s report has been sent to the Met Police, the College of Policing, and SLaM, requiring a response within 56 days. The Met Police and SLaM have been contacted for comment but have not yet issued public statements. The inquest did not find that SLaM’s failings contributed to Morgan’s death, but the coroner called for improvements in recording and monitoring patient leave.
Questions this report answers
+Why did the Met Police delay responding to Catherine Morgan’s disappearance?
The Met Police applied the Right Care Right Person policy and Affinity Protocol rigidly, refusing to investigate until checks at her registered home address were completed. This led to a delay of over three and a half hours, which the inquest found may have contributed to her death.
+What failings did the inquest identify at Lewisham Hospital?
The inquest found South London and Maudsley NHS Trust did not follow NICE guidelines for risk assessments. Unescorted leave was not properly recorded, and ward staff were unaware Catherine Morgan had been granted leave. The nurse in charge was not informed, delaying the discovery of her absence.
+What happens after the coroner’s report?
The coroner’s report has been sent to the Met Police, the College of Policing, and South London and Maudsley NHS Trust. They must respond within 56 days. The Met Police and NHS Trust have not yet issued public statements about the findings.
+Did the NHS Trust’s failings contribute to Catherine Morgan’s death?
The inquest did not find that South London and Maudsley NHS Trust’s failings contributed to her death. However, the coroner called for improvements in recording and monitoring patient leave to prevent future risks.
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