Met Police delayed Lewisham woman’s search by 3.5 hours, coroner finds

The Metropolitan Police delayed sending officers to search for a missing Lewisham woman by more than three and a half hours, a coroner has concluded. Catherine Morgan, 37, took her own life in Kent on 4 September 2024 after leaving Lewisham Hospital on unescorted leave. An inquest jury ruled the force’s handling of her case may have contributed to her death.

Coroner criticises 'overly rigid' police response

Patricia Harding, Senior Coroner for Kent and Medway, wrote an urgent letter to the Met after the inquest. She found the force applied national guidance 'overly rigidly', preventing call handlers from using their own judgement. The delay in deploying officers began when ward staff reported Catherine missing at 1.17pm. Police did not grade the case as high risk until 5pm.

Catherine’s father called the Met multiple times, warning officers she was not at her registered address and had previously attempted suicide. The force initially declined to investigate, citing the Right Care Right Person policy and Affinity Protocol. The coroner said this approach removed any opportunity for discretion while checks were conducted.

Failures at Lewisham Hospital

South London and Maudsley NHS Foundation Trust (SLaM) also faced criticism. The inquest found the trust did not follow NICE guidelines for risk assessments. Catherine was granted unescorted leave on 4 September but ward staff did not sign it out properly. The nurse in charge was unaware she had left the ward.

Catherine was due back by midday but staff only realised she was missing when her mother arrived at 12.50pm. The coroner said reliance on hourly checks was inadequate. A photograph of Catherine was not included in the emergency 'grab pack' used to locate missing patients. SLaM’s systems for monitoring voluntary patients were described as 'largely communicated by word of mouth'.

What happens next

The coroner’s prevention of future deaths report was sent to the Met Police and SLaM on 28 July 2025. The force and trust have 56 days to respond with actions taken or planned. The Met said it would review the coroner’s findings but did not provide further comment. SLaM has not yet responded publicly.

Catherine’s family has not made a public statement since the inquest. The Independent Office for Police Conduct (IOPC) confirmed it is not investigating the case.