First reported 2 Dec 2016•Latest report 24 Apr 2026
Definition
What this concern includes
Includes failures of dedicated Section 136 procedures, including information-sharing and consultation, understanding or application of powers, assessment and discharge, inter-agency policy coordination, notification, conveyance and place-of-safety arrangements.
Not included
Excludes generic mental health service deficiencies not explicitly tied to Section 136 procedures.
Excludes failures concerning unrelated assessment, consultation or care-planning processes.
Excludes general police or ambulance training, staffing or communication deficiencies unless they directly concern operation of Section 136 procedures.
Excludes outcomes or individual clinical errors that do not identify an unsafe Section 136 process or control.
Reports
17
Distinct published reports
Individual concerns
25
A report can raise multiple concerns
Date range
2016–2026
First to latest report issue date
Stated actions
41
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care4
Metropolitan Police Service4
NHS England4
College of Policing3
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
East Midlands Ambulance Service NHS Trust2
National Police Chiefs’ Council2
Nottinghamshire Police2
Pennine Care NHS Foundation Trust2
Association of Ambulance Chief Executives1
Association of Directors of Adult Social Services1
Bedfordshire Police1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Police force12
NHS trust11
National policing body5
Executive non-departmental public body4
Ministerial department4
Integrated care board3
Company limited by guarantee1
English metropolitan district council1
English unitary authority1
Health-sector membership body1
Health-system partnership1
Local health board1
Multi-service care provider1
Private limited company1
Professional body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner West London
Concerns raised1
Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Review Authorised Professional Practice guidance and consider the report’s concerns in resulting amendments.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Action
Deliver comprehensive training on Mental Health Act sections 135 and 136, including communal-area powers, warrants, and safeguarding.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Issue operational notices clarifying the lawful use of section 136 powers in communal areas.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Embed enhanced supervisory oversight and escalation processes within control-room decision-making.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Continue reinforcing Mental Health Act and Right Care, Right Person training through regular audit and quality assurance.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Metropolitan Police Service is responsible for addressing operational elements and decision-making processes and is providing the substantive response.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised2
Failure to inform next of kin how to contact the s136 suite and provide further updates
Failure to pass relevant details, including next-of-kin information, to the s136 suite
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
After police handover, the NHS trust assumes responsibility for care and appropriate next-of-kin updates.
Stated by South Yorkshire PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Data protection legislation prevents police contacting an adult’s next of kin about detention without expressed consent.
Stated by South Yorkshire PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Having complied with data protection legislation, no further action is proposed regarding next-of-kin contact.
Stated by South Yorkshire PoliceNo action considered necessaryThe respondent said that no further action was needed.
South Yorkshire (Western)
Concerns raised3
Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Lack of police training on communicating s.136 detention decisions and reasons
Lack of joined-up agency policy for s.136 detention and conveyance
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Support forces to develop local protocols with partner agencies.
Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 29 July 2025.
Action
Issue comprehensive guidance on safe conveyance, including health-based vehicle provision and arrangements for section 136 detainees.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Operational and local partnership concerns are being addressed by Nottinghamshire Police, which is providing the full response.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Agreeing a joint agency policy for section 136 detentions is the responsibility of East Midlands Ambulance Service and the police.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Lack of shared understanding of applicable local policy and working standards for s.136 detention
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Conduct a retrospective audit of operational memoranda of understanding to verify governance, implementation and alignment, identify safety gaps, and inform corrective actions.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Action
Conduct joint fact-finding with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust to clarify existing protocols and identify understanding gaps.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Lead development of a refreshed joint EMAS conveyance protocol, with consultation and sign-off by regional system partners.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Improve internal and external communication of regional policies to promote consistent awareness and application among stakeholders.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Co-lead drafting of a joint s.136 conveyance protocol with Nottinghamshire Police, incorporating input from integrated care boards and mental health trusts.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Support EMAS and partners in developing and implementing a new regional mental-health conveyance policy.
Stated by Nottinghamshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The current regional policy and interim internal governance arrangements are considered sufficient to minimise risks until the new regional policy is implemented.
Stated by Nottinghamshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
EMAS will lead development of a new regional mental health conveyance policy instead of implementing or refining the existing local multi-agency policy.
Stated by Nottinghamshire PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Develop and deliver a bespoke one-day mental-health training package based on policing guidance, legislation, service-user perspectives and scenario-based learning.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Action
Replace the Mental Health Toolkit with an interactive Mental Health SharePoint page containing policing and mental-health guidance and legislative links.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Cambridgeshire and Peterborough
Concerns raised1
Inadequacy of the Section 136 Suite
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Cambridgeshire and Peterborough Integrated Care Board is the responsible commissioner for the individual’s care and service development.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Insufficient psychiatric service response capacity out of hours for section 136 usage
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Maintain safer staffing levels and a full liaison psychiatry staff complement at St Mary’s Hospital.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Continue recruiting and retaining staff, monitor recruitment and vacancies, and implement supportive initiatives.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Publish and implement the Long-Term Workforce Plan to train, retain and reform the NHS workforce, including growth in psychiatric care staffing.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Increase mental health nursing training places by 38%.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust disputes shortages in psychiatric care provision at its St Mary’s site, stating it maintained safer staffing and a full liaison psychiatry complement.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Unavailability of mental health places of safety
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Work with police to streamline the section 136 process for access to Places of Safety.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Relevant trusts are responsible for staffing and operating mental health services.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised2
Failure to provide AMHP assessment before discharge from section 136 detention
Ambiguity in guidance on required AMHP assessment under section 136
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised2
Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals
Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of dedicated Section 136 procedures, including information-sharing and consultation, understanding or application of powers, assessment and discharge, inter-agency policy coordination, notification, conveyance and place-of-safety arrangements.
