A coroner has delivered a devastating verdict after a vulnerable woman was found dead just moments after making a desperate 999 call to police, with the service now facing serious questions about its handling of mental health emergencies.
The inquest into the death of 34-year-old Roxanne Green heard how she made a final, poignant plea to officers who attended her home in Nottinghamshire. "Am I safe?" she asked repeatedly during the encounter on February 9, 2023 - a question that would prove tragically prophetic.
A System Failure
Assistant Coroner Dr Elizabeth Didcock concluded that Nottinghamshire Police's inadequate risk assessment and failure to follow their own safeguarding procedures directly contributed to Ms Green's death. The court heard how officers left the property despite clear signs of vulnerability.
"There were missed opportunities to protect Roxanne," Dr Didcock stated in her prevention of future deaths report. "The collective failure to adequately risk assess and safeguard a vulnerable individual created a perfect storm of circumstances that led to this tragedy."
Final Moments
The sequence of events began when Ms Green, who had a history of mental health struggles, contacted emergency services expressing concerns for her welfare. Body-worn footage from responding officers captured the haunting exchange where she repeatedly sought reassurance about her safety.
Despite her evident distress and vulnerability, officers departed the scene. Mere hours later, Ms Green was discovered deceased at the same address.
Systemic Issues Exposed
The case has exposed worrying gaps in police handling of mental health crises:
- Inadequate risk assessment procedures
- Failure to follow established safeguarding protocols
- Poor communication between emergency services
- Insufficient mental health awareness training
Nottinghamshire Police has acknowledged the shortcomings and confirmed that several officers have undergone retraining since the incident.
A Family's Anguish
In a heartfelt statement, Ms Green's family described their ongoing devastation: "We are utterly broken by the loss of Roxanne. She reached out for help in her most vulnerable moment and was failed by the very system designed to protect her. Her final question - 'Am I safe?' - will haunt us forever."
The family has called for immediate reforms to ensure no other vulnerable person experiences similar failures when seeking police assistance.
Broader Implications
This case raises serious concerns about police preparedness for dealing with mental health emergencies across the UK. With increasing pressure on mental health services, police often become first responders in crises they're inadequately equipped to handle.
Mental health charities have joined the family in demanding better training and clearer protocols for officers encountering vulnerable individuals.
Nottinghamshire Police has stated it is "reviewing processes and implementing changes" following the coroner's findings.
