Met Police delay in Catherine Morgan case ruled contributory to her death

Catherine Morgan, 37, died by suicide in Kent on 4 September 2024 after leaving Lewisham Hospital on unescorted leave. An inquest jury concluded the Metropolitan Police’s delayed response may have contributed to her death. The force took 3 hours and 43 minutes to begin an investigation after her disappearance was reported.

Morgan was admitted to Lewisham Hospital as a voluntary patient on 27 August 2024 following a previous suicide attempt. On 4 September, she left the ward at 10:30 am with agreement to return by midday. When her mother arrived at 12:50 pm to take her for lunch, staff discovered she had not returned.

Delays in police response

Ward staff reported Morgan missing to the Met Police at 1:17 pm. The force initially declined to investigate, citing the Right Care Right Person policy and the Affinity Protocol. They insisted on checking her registered home address first, despite her father explaining she would not go there.

Morgan’s father called the police at 1:28 pm, referencing her earlier suicide attempt. The Met still did not act. At 2:02 pm, he confirmed she was not at her flat. The case was passed between borough command units before being graded as high risk at 5 pm. The Missing Persons Unit began its investigation at that time.

Kent Police were dispatched at 7:13 pm after cell site data located Morgan. Officers arrived at 7:47 pm, but she took her own life at 8:16 pm. The inquest heard that a call handler had raised concerns about the delay but was overruled by supervisors.

Coroner’s findings

Senior Coroner Patricia Harding concluded the Met’s application of national guidance was 'overly rigid'. She said the policy removed discretion from call handlers and dispatchers, preventing immediate deployment while checks were conducted. Harding issued a prevention of future deaths report on 28 July 2025, requiring responses from both the Met and South London and Maudsley NHS Foundation Trust within 56 days.

NHS trust failures

The inquest identified multiple failings by South London and Maudsley NHS Foundation Trust. Risk assessments were not carried out in line with NICE guidelines. Unescorted leave was not properly recorded, and the nurse in charge was unaware Morgan had been granted leave. Ward staff only realised she had not returned when her mother arrived at 12:50 pm.

Harding said the trust’s system for monitoring leave relied on hourly checks, but the nurse conducting the 12 pm check was unaware Morgan was on unescorted leave. She also noted inconsistencies in how leave was managed for voluntary patients compared to detained patients.

What happens next

The Metropolitan Police and South London and Maudsley NHS Foundation Trust must respond to the prevention of future deaths report by 23 September 2025. The Met has not yet commented on the coroner’s findings. A spokesperson for the NHS trust said it would review the report and implement any necessary changes to improve patient safety.