Recurring concern

Unsafe operation of Section 136 mental health assessment and detention procedures

First to latest report 2 Dec 2016 — 24 Apr 2026

Reports that mention this concern
17
Times this concern has been raised
25
Stated actions linked to this concern
41

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.

What is 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 and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner West London

    AI-generated summary

    Edward Muwanga · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation

    Wider context from the report

    “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation ”

    Source location

    Edward Muwanga · Prevention of Future Deaths report
    Page 5 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review Authorised Professional Practice guidance and consider the report’s concerns in resulting amendments.

    Verbatim wording from the response

    “The College of Policing recognises the risks associated with mental health incidents and we understand the critical importance of decisions about the appropriate response to such calls. The police response to mental health incidents is covered within the guidance produced by the College under the Authorised Professional Practice (APP). The APP is currently going through a formal review and we will ensure that the points highlighted within your report are fully considered within any amendments made within the review process.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 19 June 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver comprehensive training on Mental Health Act sections 135 and 136, including communal-area powers, warrants, and safeguarding.

    Verbatim wording from the response

    “The MPS acknowledges the findings of the inquest and the concerns raised in this report, and we have taken substantive steps to strengthen training, policy, and operational practice.”

    Source location

    Response from Metropolitan Police
    Page 1 · response
    Published 19 June 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue operational notices clarifying the lawful use of section 136 powers in communal areas.

    Verbatim wording from the response

    “All officers now receive structured and comprehensive training on sections 135 and 136 of the Mental Health Act. This includes specific instruction on the lawful use of section 136 powers in communal areas, with explicit clarification reinforced through operational notices issued to all frontline staff. Officers are also trained on the purpose and execution of section 135 warrants, including the respective roles of health professionals and the importance of safeguarding considerations. Training is delivered through a blended approach, combining classroom learning, scenario-based exercises, and ongoing professional development to ensure both legal understanding and effective practical application.”

    Source location

    Response from Metropolitan Police
    Page 1 · response
    Published 19 June 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed enhanced supervisory oversight and escalation processes within control-room decision-making.

    Verbatim wording from the response

    “Since the inquest, the MPS has taken further steps to strengthen these arrangements. Guidance on the application of section 136 in communal settings has been reinforced to remove any ambiguity, and updated policy and operational processes have improved consistency in identifying and executing section 135 warrants. Enhanced supervisory oversight and escalation processes are now embedded within control room decision-making. Taken together, these measures directly address the issues identified in the report and provide assurance that officers are better equipped to make lawful, informed, and proportionate decisions.”

    Source location

    Response from Metropolitan Police
    Page 2 · response
    Published 19 June 2026

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue reinforcing Mental Health Act and Right Care, Right Person training through regular audit and quality assurance.

    Verbatim wording from the response

    “Alongside this, the MPS will continue to reinforce training on Mental Health Act powers and the Right Care, Right Person framework, supported by regular audit and quality assurance to ensure consistent and effective decision-making.”

    Source location

    Response from Metropolitan Police
    Page 3 · response
    Published 19 June 2026

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Metropolitan Police Service is responsible for addressing operational elements and decision-making processes and is providing the substantive response.

    Verbatim wording from the response

    “In relation to the operational elements and decision-making processes, we have been in contact with the Metropolitan Police Service (MPS) and understand that a full response to these points is being provided.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 19 June 2026

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Andrew Herrin Dodds · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform next of kin how to contact the s136 suite and provide further updates

    Wider context from the report

    “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear. ”

    Source location

    Andrew Herrin Dodds · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to pass relevant details, including next-of-kin information, to the s136 suite

    Wider context from the report

    “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear. ”

    Source location

    Andrew Herrin Dodds · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    After police handover, the NHS trust assumes responsibility for care and appropriate next-of-kin updates.

    Verbatim wording from the response

    “Once this handover has been completed the police role ceases completely and the NHS trust assume responsibility for the individual, along with any relevant updates to next of kin if assessed as appropriate and in line with Data Protection legislative requirements. This is in line with the protocols in place between South Yorkshire Police and the Integrated Care Boards.”

    Source location

    Response from South Yorkshire Police
    Page 2 · response
    Published 19 November 2025

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Data protection legislation prevents police contacting an adult’s next of kin about detention without expressed consent.

    Verbatim wording from the response

    “Data Protection legislation would preclude us from contacting the next of kin to share information about an adult without their expressed consent, this would include the fact that they have been detained under S136 MHA or taken to a medical establishment. This would be classed as health data and therefore falls within the stronger legal protections of the Data Protection legislation.”

    Source location

    Response from South Yorkshire Police
    Page 2 · response
    Published 19 November 2025

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Having complied with data protection legislation, no further action is proposed regarding next-of-kin contact.

    Verbatim wording from the response

    “Having reviewed our actions, we complied with Data Protection legislation and therefore we do not propose any further action in relation to this matter.”

    Source location

    Response from South Yorkshire Police
    Page 3 · response
    Published 19 November 2025

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Kaine Regan FLETCHER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy

    Wider context from the report

    “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance. Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows: • The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception. • EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards. Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows: • There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them. • Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention. My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health. The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983. ”

    Source location

    Kaine Regan FLETCHER · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of police training on communicating s.136 detention decisions and reasons

    Wider context from the report

    “4. Police training on s.136 MHA 1983 detention and mental health I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents. ”

    Source location

    Kaine Regan FLETCHER · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of joined-up agency policy for s.136 detention and conveyance

    Wider context from the report

    “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance. Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows: • The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception. • EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards. Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows: • There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them. • Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention. My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health. The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983. ”

    Source location

    Kaine Regan FLETCHER · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Support forces to develop local protocols with partner agencies.

    Verbatim wording from the response

    “• Support forces in developing local protocols with partner agencies”

    Source location

    Response from College of Policing
    Page 4 · response
    Published 29 July 2025

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue comprehensive guidance on safe conveyance, including health-based vehicle provision and arrangements for section 136 detainees.

    Verbatim wording from the response

    “NHS England has issued comprehensive guidance, including on the conveyance of individuals detained under section 136, which sets out that:”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 29 July 2025

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational and local partnership concerns are being addressed by Nottinghamshire Police, which is providing the full response.

    Verbatim wording from the response

    “We have carefully considered the matters of concern raised in your Regulation 28 report. This response outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect of the Mental Health Act. In relation to the operational elements and local partnership working, we have been in contact with Nottinghamshire Police and understand that a number of measures are being implemented and a full response to the concerns you have raised is being provided.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 29 July 2025

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Agreeing a joint agency policy for section 136 detentions is the responsibility of East Midlands Ambulance Service and the police.

    Verbatim wording from the response

    “Your concern about the lack of agreed joint agency policy between East Midlands Ambulance Service and the police on section 136 detentions is a matter for those organisations.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 29 July 2025

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Kaine Regan FLETCHER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kaine Regan FLETCHER died on 3 July 2022 after deteriorating during a period of restraint following detention under section 136 of the Mental Health Act, with cocaine and other substances also identified in the stated cause of death. The report raises concern that the police and ambulance service did not share an understanding of the applicable local policy and working standards for managing section 136 incidents, creating a potential risk of preventable future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of shared understanding of applicable local policy and working standards for s.136 detention

    Wider context from the report

    “Confusion over applicable local policy and working standards for dealing with s.136 detention I am concerned that there is a lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention. At the outset of this investigation, a direction was given for disclosure of “Local memoranda or policies concerning how EMAS and Notts police jointly manage health incidents”. In response to that direction, a number of policies were disclosed, including a document entitled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedures”. Various versions of this policy were disclosed to the coroner, including a 2018, 2021 and 2024 version. During the course of the inquest so far, I heard evidence from both the police and the ambulance service in relation to the local policy for managing s.136 incidents. The police and the ambulance service do not share an understanding of which policy they are expected to adhere to and whether there is a joint local policy. The police consider that the document above (as amended) is the applicable framework, whilst EMAS are currently unable to tell me if this policy has agreed to by them, notwithstanding that they appear as one of the agencies that formed part of the working group for each version of the MOU. The witness who gave policy evidence on behalf of EMAS told me that they only work to their own internal local standard, which is different to that in the MOU. Persons detained under s.136 of the Mental Health Act 1983 are some of the most vulnerable in society. Their liberty has been removed, and they are reliant upon state agencies to protect their right to life. I am extremely concerned that there is no joined up thinking, or understanding, between the police and the ambulance service as to which policy and which working standards apply when furthering the protection of that right. I am concerned that this lack of basic understanding of policy and working standards by emergency services, if it persists, poses a risk of preventable future deaths. ”

    Source location

    Kaine Regan FLETCHER · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a retrospective audit of operational memoranda of understanding to verify governance, implementation and alignment, identify safety gaps, and inform corrective actions.

    Verbatim wording from the response

    “EMAS is committed to continuous improvement and ensuring the highest standards of patient safety and governance. In response to the issues identified, EMAS has initiated a retrospective audit of all operational Memoranda of Understanding (MoUs) received and implemented across the organisation.”

    Source location

    2025-0363 - Response from East Midlands Ambulance Service
    Page 2 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct joint fact-finding with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust to clarify existing protocols and identify understanding gaps.

    Verbatim wording from the response

    “EMAS will initiate a joint fact-finding exercise with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust (NHCHT) to clarify existing protocols and identify gaps in understanding.”

    Source location

    2025-0363 - Response from East Midlands Ambulance Service
    Page 3 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Lead development of a refreshed joint EMAS conveyance protocol, with consultation and sign-off by regional system partners.

    Verbatim wording from the response

    “EMAS will lead the development of a refreshed joint EMAS conveyance protocol, ensuring full consultation and sign-off by all system partners within the EMAS region.”

    Source location

    2025-0363 - Response from East Midlands Ambulance Service
    Page 3 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve internal and external communication of regional policies to promote consistent awareness and application among stakeholders.

    Verbatim wording from the response

    “EMAS will improve internal and external communication regarding regional policies to ensure consistent application and awareness across all stakeholders.”

    Source location

    2025-0363 - Response from East Midlands Ambulance Service
    Page 3 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-lead drafting of a joint s.136 conveyance protocol with Nottinghamshire Police, incorporating input from integrated care boards and mental health trusts.

    Verbatim wording from the response

    “EMAS and Nottinghamshire Police will co-lead the drafting of a joint s.136 conveyance protocol, with input from system partners including Integrated Care Boards (ICBs) and Mental Health Trusts.”

    Source location

    2025-0363 - Response from East Midlands Ambulance Service
    Page 4 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Support EMAS and partners in developing and implementing a new regional mental-health conveyance policy.

    Verbatim wording from the response

    “EMAS have advised that instead they intend to lead on the creation of a new regional Mental Health (MH) conveyance policy with system partners, and in the interim continue to utilise their current regional policy. We understand this is due to complexities across county boundaries where localised agreements may cause confusion resulting in less optimal patient experience. We remain in regular contact with EMAS and will fully support the development of this new regional policy being implemented in the most expedient way possible.”

    Source location

    2025-0363 - Response from Nottingham and Nottinghamshire Police
    Page 2 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The current regional policy and interim internal governance arrangements are considered sufficient to minimise risks until the new regional policy is implemented.

    Verbatim wording from the response

    “EMAS have advised that instead they intend to lead on the creation of a new regional Mental Health (MH) conveyance policy with system partners, and in the interim continue to utilise their current regional policy. We understand this is due to complexities across county boundaries where localised agreements may cause confusion resulting in less optimal patient experience. We remain in regular contact with EMAS and will fully support the development of this new regional policy being implemented in the most expedient way possible.”

    Source location

    2025-0363 - Response from Nottingham and Nottinghamshire Police
    Page 2 · response
    Published 23 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    EMAS will lead development of a new regional mental health conveyance policy instead of implementing or refining the existing local multi-agency policy.

    Verbatim wording from the response

    “We have consulted with colleagues from EMAS to address this issue and suggested several potential remedies. We have been advised by the EMAS Head of Mental Health, that after careful consideration their Chief Executive has directed that they will not be seeking to implement or refine the existing multi-agency policy and procedure for Nottingham and Nottinghamshire.”

    Source location

    2025-0363 - Response from Nottingham and Nottinghamshire Police
    Page 2 · response
    Published 23 July 2025

    Open published response

  5. Inner North London

    AI-generated summary

    Michael James Crane · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act

    Wider context from the report

    “1) The MPS constable who gave evidence at the inquest, told me that: • if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe; • the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and • there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such. ”

    Source location

    Michael James Crane · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and deliver a bespoke one-day mental-health training package based on policing guidance, legislation, service-user perspectives and scenario-based learning.

    Verbatim wording from the response

    “In early 2019, the MPS reviewed the mental health training that was delivered to officers and developed a bespoke one-day training package. The content was based on the College of Policing Authorised Professional Practice (APP), the London Crisis Care Pathway and the MPS Mental Health Toolkit. It incorporated relevant legislation (including the Mental Health Act 1983) and the voice of the service user, lessons learnt; and tested learning through a series of animated scenarios. It encouraged officers to implement their learning as well as seeking to highlight the perspectives of service users and mental health professionals. This training was concluded in April 2020 and has been delivered to 10,300 officers.”

    Source location

    Response from Metropolitan Police Service
    Page 2 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace the Mental Health Toolkit with an interactive Mental Health SharePoint page containing policing and mental-health guidance and legislative links.

    Verbatim wording from the response

    “The MPS had a Mental Health Toolkit up to July 2024. This was a living document containing guidance for officers on how to deal with all aspects of people who are mentally unwell or have mental illness. This has now been superseded by the Mental Health SharePoint page which provides guidance and is also interactive. It contains sections on all topics of policing and mental health and has links to the associated legislation.”

    Source location

    Response from Metropolitan Police Service
    Page 3 · response
    Published 1 November 2024

    Open published response

  6. Cambridgeshire and Peterborough

    AI-generated summary

    DECLAN GORDON GERARD MORRISON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequacy of the Section 136 Suite

    Wider context from the report

    “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS. (2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found. This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act. (3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death. (4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained, in order to prevent his death. ”

    Source location

    DECLAN GORDON GERARD MORRISON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Cambridgeshire and Peterborough Integrated Care Board is the responsible commissioner for the individual’s care and service development.

    Verbatim wording from the response

    “We note that your Report is also addressed to Cambridgeshire and Peterborough Integrated Care Board (ICB), the responsible commissioner for Declan’s care, and we are aware they have responded to the Coroner separately to outline the learning they have undertaken in response to this case and the next steps they will be taking to enhance service development for complex patients. We are aware that this includes work to better support patients under a Mental Health Act and an outline of the ICB’s work to transform services for people with mental health, learning disabilities and autism, including ensuring that there is no inappropriate detention of individuals with learning disabilities and/or who are autistic.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 24 October 2024

    Open published response

  7. Inner West London

    AI-generated summary

    Mr Roberto Bottello · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient psychiatric service response capacity out of hours for section 136 usage

    Wider context from the report

    “7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services. ”

    Source location

    Mr Roberto Bottello · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain safer staffing levels and a full liaison psychiatry staff complement at St Mary’s Hospital.

    Verbatim wording from the response

    “• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.”

    Source location

    Response from Central and NW London NHS
    Page 5 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue recruiting and retaining staff, monitor recruitment and vacancies, and implement supportive initiatives.

    Verbatim wording from the response

    “• At CNWL, we recognise the fluid nature of this situation and affirm our dedication to consistently recruiting and retaining our valuable staff. We are committed to continuously monitoring recruitment and vacancies, as well as implementing supportive initiatives.”

    Source location

    Response from Central and NW London NHS
    Page 5 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish and implement the Long-Term Workforce Plan to train, retain and reform the NHS workforce, including growth in psychiatric care staffing.

    Verbatim wording from the response

    “Workforce and staffing levels continue to be a challenge across the NHS, and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history and includes focus on growing the psychiatric care workforce.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase mental health nursing training places by 38%.

    Verbatim wording from the response

    “In addition to education and training for clinical psychologists and child and adolescent psychotherapists, over the next three years NHS England has committed funding of over £600 million to grow the wider psychological professions workforce through training approximately 15,000 more individuals to undertake psychological therapist and psychological practitioner roles. Training places for mental health nursing will also increase by 38%. The Long-Term Workforce Plan makes a commitment to keep the mental health workforce under review.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 22 February 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    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.

    Verbatim wording from the response

    “• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.”

    Source location

    Response from Central and NW London NHS
    Page 5 · response
    Published 22 February 2024

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    PETER MARTIN AARON FLEMING · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of mental health places of safety

    Wider context from the report

    “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years. ”

    Source location

    PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with police to streamline the section 136 process for access to Places of Safety.

    Verbatim wording from the response

    “Whilst it is best practice that a service user presenting with a mental health concerns is taken to a mental health Place of Safety, this could not be achieved on the particular day in question as all the mental health Places of Safety within the Trust were taken. However, Mr Fleming was conveyed to the Accident & Emergency Department at Heartlands Hospital which is an appropriate Place of Safety and indeed there are a number of A&E departments across the Birmingham and Solihull area where their services can be taken too as Places of Safety. In terms of its own provision the Trust has three Places of Safety available across the organisation. The pressure on these facilities is multi-factorial. Work is ongoing in this area with the Police to streamline the s.136 process.”

    Source location

    Response from Birmingham and Solihull Mental Health Foundation Trust
    Page 1 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.

    Verbatim wording from the response

    “This letter responds to the concerns raised in your report relevant to NHS England. It is not within NHS England’s remit to respond to many of the concerns raised, particularly relating to Birmingham and Solihull Mental Health Trust (BSMHFT). NHS England has asked to be sighted on the responses from BSMHFT and Birmingham and Solihull Integrated Care Board (ICB) and will give due consideration to their responses.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 18 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Relevant trusts are responsible for staffing and operating mental health services.

    Verbatim wording from the response

    “The responsibility for the staffing and operations of mental health services lies with the relevant trust, however, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 July 2023

    Open published response

  9. Bedfordshire and Luton

    AI-generated summary

    James EMMERSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide AMHP assessment before discharge from section 136 detention

    Wider context from the report

    “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”). The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders. Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital. Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”. “The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment. “The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.” Jamie was never examined by an AMPH only by a lone section 12 approved junior doctor and he was discharged from his s.136. In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.” This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises. I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to. ”

    Source location

    James EMMERSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Ambiguity in guidance on required AMHP assessment under section 136

    Wider context from the report

    “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”). The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders. Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital. Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”. “The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment. “The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.” Jamie was never examined by an AMPH only by a lone section 12 approved junior doctor and he was discharged from his s.136. In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.” This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises. I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to. ”

    Source location

    James EMMERSON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Milton Keynes

    AI-generated summary

    Hedley Frederick ROBINSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hedley Frederick ROBINSON died on 14 April 2019 after sustaining multiple stab wounds inflicted in Newport Pagnell on 24 March 2019. The concern identified was that a Mental Health Act section 136 assessment was conducted without full information or discussion with relevant senior police officers and others involved in the assailant’s care, prompting concern about the operation of section 136 procedures in Milton Keynes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to discuss S. 136 Mental Health Act assessments with relevant police officers and other involved care professionals

    Wider context from the report

    “I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes. ”

    Source location

    Hedley Frederick ROBINSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure that S. 136 Mental Health Act assessments use full information held by relevant services

    Wider context from the report

    “I am concerned that the S. 136 Mental Health Act assessment was conducted without full information held by CNWL or discussion with senior police officers and others who had been involved in the care of the deceased’s assailant. There needs to be an urgent review of the operation of S. 136 procedures in Milton Keynes. ”

    Source location

    Hedley Frederick ROBINSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026