4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association of Ambulance Chief Executives Bedfordshire Police East of England Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
East of England Ambulance Service NHS Trust
Implement the approved national section 136 ambulance guidance locally with partner-agency representation.
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East of England Ambulance Service NHS Trust
Update the community-setting guidance for requesting conveyance of patients detained under the Mental Health Act.
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East of England Ambulance Service NHS Trust
Send the updated conveyance guidance to the coroner and share it with regional police forces and mental health partners.
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Bedfordshire Police
Complete and sign off the revised local section 136 multi-agency policy.
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Bedfordshire Police
Forward the signed-off revised multi-agency policy to the Coroner.
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AI-generated summary
LEON BRIGGS · 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
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
Wider context from the report “1. Adequacy of the local S136 Multi-Agency Policy
Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons:
(i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction)
(ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay ;
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end.
N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCG) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy making.
” Source location LEON BRIGGS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved national section 136 ambulance guidance locally with partner-agency representation.
Verbatim wording from the response “The National Ambulance s.136 Guidance was recently approved (November 2021) by the National Ambulance Service Medical Directors group (NASMED), which is a working group that reports to the Association of Ambulance Chief Executives (AACE). These changes will now be implemented locally and this work is being led by the Bedfordshire AMHPs (on behalf of the Crisis Care Concordat) and the forum includes representation from both EEAST and Bedfordshire Police.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the community-setting guidance for requesting conveyance of patients detained under the Mental Health Act.
Verbatim wording from the response “EEAST’s Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document ‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review and update has been completed in December 2021. This will also be shared with the regional police forces and mental health partners through the regional Approved Mental Health Practitioner.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send the updated conveyance guidance to the coroner and share it with regional police forces and mental health partners.
Verbatim wording from the response “EEAST’s Mental Health team have also been working on updating the guidance documents for our partners in relation to managing s.136 patients within the community setting. This document ‘Requesting Conveyance for Patients Detained under the MHA’ will be sent to you once the review and update has been completed in December 2021. This will also be shared with the regional police forces and mental health partners through the regional Approved Mental Health Practitioner.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and sign off the revised local section 136 multi-agency policy.
Verbatim wording from the response “As you are aware from the evidence at the inquest, the policy which applied in 2013 had been superseded. The current policy is under a task and finish group. It was reviewed by the current National Lead for Mental Health, Deputy Chief Constable ████████, whose team stated they thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, update and confirm understanding, which took place with the benefit of the concerns you have identified. A revised policy is due to be signed-off this year. I will ask my legal services department to provide you with a final copy as soon as it has been signed off.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forward the signed-off revised multi-agency policy to the Coroner.
Verbatim wording from the response “As you are aware from the evidence at the inquest, the policy which applied in 2013 had been superseded. The current policy is under a task and finish group. It was reviewed by the current National Lead for Mental Health, Deputy Chief Constable ████████, whose team stated they thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, update and confirm understanding, which took place with the benefit of the concerns you have identified. A revised policy is due to be signed-off this year. I will ask my legal services department to provide you with a final copy as soon as it has been signed off.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
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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 Local S136 policy is outside the scope of comment for this national ambulance organisation.
Verbatim wording from the response “With regard to your matter of concern about the adequacy of the local S136 Multi-Agency Policy. We are unable to comment on local S136 policy, but we can confirm that the national S136 guidance has recently been revised, updated, and issued nationally. The revised guidance includes wording to highlight that the police officer on scene should call the local ambulance service and include in the information passed whether the patient is being actively restrained and if so how, and if acute behavioural disturbance (ABD) is suspected. Ambulance trusts will assign a Category 2 response to patients detained under S136 and suspected of having ABD unless there are other immediately life-threatening clinical features that would warrant a Category 1 response.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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20 Jan 2020 Deborah Margaret LAMONT · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Lack of specific guidance on classification of hotel rooms under the s136(1A) exception View source
Linked responses
College of Policing South Wales Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
South Wales Police
Fully consider the use of hotel rooms and section 136 under the Mental Health Act as an interim force safety issue.
View source
South Wales Police
Add a specific note on hotel rooms and section 136 to force guidance.
View source
South Wales Police
Include a specific note on hotel rooms and section 136 within force training.
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College of Policing
Amend College guidance on using section 136 powers in hotel rooms.
View source
College of Policing
Circulate a summary of the hotel-room section 136 issue to police force mental health leads across England and Wales.
View source
College of Policing
Work with the Home Office to assess whether national guidance on section 136 and hotel rooms requires relevant changes.
View source
College of Policing
Keep police forces informed of developments concerning section 136 use in hotel rooms.
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AI-generated summary
Deborah Margaret LAMONT · 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
Deborah Margaret Lamont travelled to a hotel on 28 March 2019, where she suspended herself by a ligature and was found deceased by police officers shortly after 11pm. The principal concern was that police officers might incorrectly conclude that the power under section 136 of the Mental Health Act did not apply in a hotel room, potentially placing an individual at risk of death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific guidance on classification of hotel rooms under the s136(1A) exception
Wider context from the report “Regard was had during the Inquest as to the Department of Health Guidance to the changes to the MHA 1983, published in October 2017. No specific guidance as to the classification of a hotel room for the purposes of whether that falls within the exception in s136 (1A) is provided.
Whilst it is accepted, both by myself, & in the Guidance, as above, that there will always be some degree of discretion for a police officer to exercise in relation to the interpretation of whether a person is living in a hotel room, the evidence here was that DL had booked into the room for one night & had no more than a bare licence to occupy it (which would contrast with, for example, an individual or family temporarily housed in a hotel room by a local authority, or a care home resident occupying indefinitely a room in a care home).
Hence, based upon the evidence I received, and my interpretation (in these particular circumstances) of whether a hotel room came within s136 (1A) MHA, I found it likely that ████████ did have the power to remove DL to a place of safety
My concern is that faced with a similar situation (albeit in circumstances were the officer did consider a person was suffering from mental disorder and requiring of immediate care, or control), an officer may reach the same conclusion as ████████ determine the power to remove did not exist, and this may lead to a risk of death to that individual.
” Source location Deborah Margaret LAMONT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fully consider the use of hotel rooms and section 136 under the Mental Health Act as an interim force safety issue.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a specific note on hotel rooms and section 136 to force guidance.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include a specific note on hotel rooms and section 136 within force training.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend College guidance on using section 136 powers in hotel rooms.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a summary of the hotel-room section 136 issue to police force mental health leads across England and Wales.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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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 the Home Office to assess whether national guidance on section 136 and hotel rooms requires relevant changes.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep police forces informed of developments concerning section 136 use in hotel rooms.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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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 Further national guidance or legislative amendment on section 136 and hotel rooms is assigned to the Home Office and College of Policing.
Verbatim wording from the response “The Chief Constable notes that the College will circulate a summary of this issue to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. It is noted that in addition, the College has raised the issue with the Home Office and will work together to assess the need for relevant changes to the current national guidance (APP) in relation to the use of s136 and hotel rooms. The College will ensure that all Forces are kept appraised of developments.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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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 Use of section 136 in hotel rooms cannot be mandated because there is no legal basis; officers must assess each case individually.
Verbatim wording from the response “As this is a matter of law, the College has sought its own legal advice to assist in providing this response. The advice received agreed with your assessment that someone ‘living’ in a room implies that the person normally resides in that place and is not there temporarily. There are no definitions provided within the legislation and no stated cases that assist in providing clarification. Consequently, the use of s136 in these circumstances is a subjective one and requiring individual assessment and interpretation. In other words, the use of s136 in the case of Deborah Lamont could have been a consideration.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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Concerns raised 2
Inadequate criteria for identifying the most appropriate place of safety View source Unclear responsibilities for transporting someone detained under Section 136 MHA 1983 View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Meirion James · 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
Meirion James was arrested for assaulting his mother and later became agitated at Haverfordwest Police station. During restraint, he was placed prone, stopped breathing and died from positional asphyxia. The report raised concerns about police restraint training, arrangements for people detained under Section 136 of the Mental Health Act, and training concerning Appropriate Adults.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate criteria for identifying the most appropriate place of safety
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” Source location Meirion James · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear responsibilities for transporting someone detained under Section 136 MHA 1983
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” Source location Meirion James · Prevention of Future Deaths report
Open source report
28 Dec 2018 Mr Gregory Rekowski · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Lack of clarity about police powers and role for Section 136 from-home cases View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr Gregory Rekowski · 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
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity about police powers and role for Section 136 from-home cases
Wider context from the report “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst other agencies .
” Source location Mr Gregory Rekowski · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, revise and enhance multi-agency procedures through sessions involving all named partner organisations.
Verbatim wording from the response “Several distinct sessions were convened to review, revise and enhance our existing procedures from multiple perspectives. These sessions each included insight and oversight from all partner organisations named in this letter.” Source location 2018-0411-Response-by-GMCA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Verbatim wording from the response “We have now drawn together a pan-GM protocol for response, developed specifically in order to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk; and to promote communication and escalation at the first point that a common understanding may falter.” Source location 2018-0411-Response-by-GMCA
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider better disseminating police powers, obligations and limitations to partner agencies through joint working initiatives.
Verbatim wording from the response “It is accepted that there may be a requirement to improve the understanding amongst partner agencies about police powers in responding to concerns for welfare where the person in question is in a private dwelling. However, the police officers who gave evidence as part of the inquest proceedings demonstrated that they had an accurate understanding of their powers – and the limitations thereon – under s.136. Where a concern for welfare is received in relation to an individual who is within a private dwelling, there is an option under s.135 of the same Act to require the attendance of qualified mental health practitioners to undertake a formal mental health assessment, following which it will be possible for officers to convey an individual found to require detention under the Act to a health-based place of safety.” Source location 2018-0411-Response-by-Greater-Manchester-Police
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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 Detention under section 136 was lawful because the person was found in the street, not a private dwelling.
Verbatim wording from the response “Response: Had Mr Rekwowski been taken to hospital under s.136 of the Mental Health Act 1983 (MHA) from his home address on 17 September 2017, this would have been unlawful as the exercise of powers under s.136 requires that the person who is the subject of detention is not in their own home (s.136(1A)). When police attended on 17 September, Mr Rekwowski was, in actual fact, found to be in the street and was lawfully detained pursuant to the police’s s.136 powers as he was not in a private dwelling. This is confirmed within police documentation disclosed in the Inquest proceedings:” Source location 2018-0411-Response-by-Greater-Manchester-Police
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29 Oct 2018 Rosario CORDERO-SANZ · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Inadequate understanding of section 136 Mental Health Act and mental health issues among special police officers View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Rosario CORDERO-SANZ · 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
Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate understanding of section 136 Mental Health Act and mental health issues among special police officers
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues .
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Source location Rosario CORDERO-SANZ · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue mental-health training and partnership working through annual officer safety training.
Verbatim wording from the response “In general terms the MPS response to incidents involving people with mental illness has evolved significantly over the last few years and continues to do so. We are committed to continual training and partnership working which has been incorporated into the annual officer safety training programme for all officers, including MSC. MSC officers are provided with mental health training in their foundation course which includes awareness of signs, symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, which includes training, awareness and support for all officers. MSC are also incorporated into the Home Office funded MIND Blue Light Champion Programme, whereby selected MSC officers, alongside regular officers, are trained as mental health champions.” Source location 2018-0307-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and operate a mental-health and wellbeing campaign providing training, awareness and support to officers.
Verbatim wording from the response “In general terms the MPS response to incidents involving people with mental illness has evolved significantly over the last few years and continues to do so. We are committed to continual training and partnership working which has been incorporated into the annual officer safety training programme for all officers, including MSC. MSC officers are provided with mental health training in their foundation course which includes awareness of signs, symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, which includes training, awareness and support for all officers. MSC are also incorporated into the Home Office funded MIND Blue Light Champion Programme, whereby selected MSC officers, alongside regular officers, are trained as mental health champions.” Source location 2018-0307-Response-by-Metropolitan-Police
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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 Section 136 would not have assisted because it does not apply to people inside private dwellings.
Verbatim wording from the response “S136 Mental Health Act would not have assisted the MSC officers in this particular situation because it does not apply to a person inside a private dwelling.” Source location 2018-0307-Response-by-Metropolitan-Police
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30 Nov 2017 Lindsey Theresa Hassall · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to keep records of information provided verbally by Police Officers in the s.136 suite View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Lindsey Theresa Hassall · 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
Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to keep records of information provided verbally by Police Officers in the s.136 suite
Wider context from the report “• There is no provision for a record to be kept of the information, which Police Officers provide verbally to the RAID practitioners in the s.136 suite. The inquest heard that there was a record of the initial circumstances but no further record was kept . (Pennine Care)
” Source location Lindsey Theresa Hassall · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement recording of police verbal handovers on paper history sheets, with access for the assessing doctor and AMHP and subsequent upload to PARIS.
Verbatim wording from the response “A plan has been prepared to ensure that staff record information from a verbal handover from the police on a paper history sheet and ensure the assessing doctor and AMHP have access to this so they can review the information. This will be uploaded onto PARIS once the assessment is completed. The following actions are in place:” Source location 2017-0429-Responses
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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 Develop and display a laminated flowchart guiding s136 handover recording, documentation access and referral processes.
Verbatim wording from the response “▪ Flowchart to be developed which reflects guidance in staff briefing – laminated copy to be displayed in 136 suite so it is available to staff coordinating and undertaking s136 assessments.” Source location 2017-0429-Responses
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include the new s136 documentation and referral guidance in staff briefings and local induction processes, and add it to the s136 operating procedure and policy.
Verbatim wording from the response “▪ Advice to be included in staff briefing.” Source location 2017-0429-Responses
Open published response
2 Dec 2016 Peter Daniel Usher · Prevention of Future Deaths report East London
View report summary
Concerns raised 3
Failure to inform the on-call doctor of Section 136 assessment arrivals and outcomes View source Inadequate medical staffing for Section 136 assessments View source Failure to notify an AMHP of planned Section 136 assessments View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Peter Daniel Usher · 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 Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.
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 the on-call doctor of Section 136 assessment arrivals and outcomes
Wider context from the report “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment. He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher .
” Source location Peter Daniel Usher · Prevention of Future Deaths report
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 Inadequate medical staffing for Section 136 assessments
Wider context from the report “5. The junior doctor gave evidence to confirm that he was the only doctor available for 11 wards and 200 patients . It would appear from information provided by the Trust, that the number of Section 136 assessments is increasing substantially and therefore there is a concern in relation to adequate medical staffing .
” Source location Peter Daniel Usher · Prevention of Future Deaths report
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 notify an AMHP of planned Section 136 assessments
Wider context from the report “3. The Trust policy requires that an AMHP (Approved Mental Health Professional) be notified of the planned assessment . This also did not take place .
” Source location Peter Daniel Usher · Prevention of Future Deaths report
Open source report
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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 the Goodmayes on-call doctors’ workload and undertake a follow-up audit of junior doctors’ workload and the impact of changes.
Verbatim wording from the response “5 | NELFT is currently in the process of reviewing the workload of the Goodmayes on call doctors. We aim to implement changes by beginning of February. An audit on junior doctor on call workload will be undertaken at the beginning of March 2017 to see if the changes have had an impact on their workload, and what other measures can be put in place to reduce the pressure associated with the workload, when completing s136 assessments.” Source location 2016-0428-Response-by-NELFT-NHS-Trust
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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 Approval of proposed changes to the s136 form rests with the Metropolitan Police Service.
Verbatim wording from the response “However this is not always done leaving both Goodmayes and the Police open to criticism. By reducing the section mentioned above and adding a “signature” box this legal requirement would be complied with. These adaptions would have to be passed through the Metropolitan Police for approval. However this process is invariably lengthy, there is additionally the consideration that the MPS, will be moving to digital paperwork, as such it is unknown whether the proposal will be accepted.” Source location 2016-0428-Response-by-Borough-Mental-Team
Open published response
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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 Changes to the s136 form cannot be given a realistic timescale because approval may be protracted and digital paperwork is planned.
Verbatim wording from the response “However this is not always done leaving both Goodmayes and the Police open to criticism. By reducing the section mentioned above and adding a “signature” box this legal requirement would be complied with. These adaptions would have to be passed through the Metropolitan Police for approval. However this process is invariably lengthy, there is additionally the consideration that the MPS, will be moving to digital paperwork, as such it is unknown whether the proposal will be accepted.” Source location 2016-0428-Response-by-Borough-Mental-Team
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.