Nicholas Ledger: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 31/08/2023

Ref: 2023-0314

Deceased name: Nicholas Ledger

Coroner name: Adam Smith

Coroner Area: Inner North London

Category: Suicide (from 2015)

This report is being sent to: College of Policing and Metropolitan Police

Chief Executive Officer College of Policing 1- 6 Citadel Place Tinworth Street London SE11 5EF
I am: Adam Smith Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP
I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29.
On 23 February 2023, JDP Stevens, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Nicholas Leger, aged 32 years. The investigation concluded at the end of the inquest on 12 June 2023.  

I made a determination of death by suicide.
The medical cause of death was:
1(a) Suspension by ligature
Mr Leger had been the subject of a Metropolitan Police investigation following a criminal allegation made in March 2022.
He was arrested and interviewed under caution at the end of May 2022, following which he was bailed. That bail was converted to RUI (released under investigation) in August 2022. He attended voluntarily a further interview on 5 November 2022.
On 23 January 2023, the CPS authorised that he be charged. This led to the generation of a PCR (Postal Charge Requisition) which was posted to him on 16 February 2023. This did not arrive at Mr Leger’s address until after his death. However, Mr Leger learnt of the charge via his solicitor on the morning of 20 February 2023. Sometime between 7:30pm and 10:30pm on 20 February 2023, he took his own life.
He had previously attempted to take his own life on 23 March 2022, after he had learnt of the allegation made against him. The investigating officer (OIC) was aware of this as Mr Leger had disclosed it when asked questions regarding his mental health and welfare at the times of the two interviews he attended. Although he had indicated at the times of the interviews that he had no concerns regarding his mental health/welfare, he also stated on 5 November 2022 that his mental health had suffered since the alleged incident.
This was the last date that any assessment was made of his mental health. By the time that he was sent the PCR (charging him with an offence that carried a maximum life sentence), he had been “RUI’d” for almost 6 months and it was more than 3 months since there had last been any formal assessment by the police of his mental health and risk of suicide or self-harm.
During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
I received evidence, in particular from the investigating officer (OIC), who dealt with the investigation into the allegation against Mr Leger, and from an investigator from the Metropolitan Police’s Directorate of Professional Standards (DPS), who conducted an investigation on behalf of the IOPC into the way in which the criminal investigation was undertaken, in particular the consideration of Mr Leger’s welfare and support offered to

I heard evidence:
·       That when a person who has been RUI’d is charged, standard practice (in accordance with current Metropolitan Police policies and procedures) is for that charge to be communicated to them via a PCR with no advance warning.
·       That this is the case regardless of the offence, or seriousness of the offence, with which they are being charged.
·       That in exceptional circumstances, where an individual is considered to be in a high-risk category, arrangements can be made for the PCR to be delivered in person and/or for a third party to be present to provide support.
·       That it is recognised that certain types of allegation, such as a sexual allegation (as was the case here), may carry a higher risk. This, of itself, does not place an individual into a high-risk category for the purposes of delivering the news that they are to be charged (by way of a PCR).
·       That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information.
·       That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
·       At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
·       Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
·       Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
·       Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a
police station for interview, once they have left the police station there are no such formal procedures (as above), notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
·       Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
In Mr Leger’s case, the relevant policies and procedures were those of the Metropolitan Police. However, these issues clearly arise at a wider (national) level and, as head of the College of Policing, you have overall responsibility for policies/guidance disseminated at a national level.
In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 August 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
I have sent a copy of my report to the following.
·       The parents of Nicholas Leger
·       HHJ Thomas Teague QC, Chief Coroner of England & Wales
I am under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.
919 June 2023