First reported 2 Dec 2016•Latest report 24 Apr 2026
Definition
What this concern includes
Includes failures of dedicated Section 136 procedures, including information-sharing and consultation, understanding or application of powers, assessment and discharge, inter-agency policy coordination, notification, conveyance and place-of-safety arrangements.
Not included
Excludes generic mental health service deficiencies not explicitly tied to Section 136 procedures.
Excludes failures concerning unrelated assessment, consultation or care-planning processes.
Excludes general police or ambulance training, staffing or communication deficiencies unless they directly concern operation of Section 136 procedures.
Excludes outcomes or individual clinical errors that do not identify an unsafe Section 136 process or control.
Reports
17
Distinct published reports
Individual concerns
25
A report can raise multiple concerns
Date range
2016–2026
First to latest report issue date
Stated actions
41
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care4
Metropolitan Police Service4
NHS England4
College of Policing3
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
East Midlands Ambulance Service NHS Trust2
National Police Chiefs’ Council2
Nottinghamshire Police2
Pennine Care NHS Foundation Trust2
Association of Ambulance Chief Executives1
Association of Directors of Adult Social Services1
Bedfordshire Police1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Police force12
NHS trust11
National policing body5
Executive non-departmental public body4
Ministerial department4
Integrated care board3
Company limited by guarantee1
English metropolitan district council1
English unitary authority1
Health-sector membership body1
Health-system partnership1
Local health board1
Multi-service care provider1
Private limited company1
Professional body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Bedfordshire and Luton
Concerns raised1
Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement the approved national section 136 ambulance guidance locally with partner-agency representation.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 October 2021.
Action
Update the community-setting guidance for requesting conveyance of patients detained under the Mental Health Act.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 October 2021.
Action
Send the updated conveyance guidance to the coroner and share it with regional police forces and mental health partners.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 October 2021.
Action
Complete and sign off the revised local section 136 multi-agency policy.
Stated by Bedfordshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 13 October 2021.
Action
Forward the signed-off revised multi-agency policy to the Coroner.
Stated by Bedfordshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 13 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local S136 policy is outside the scope of comment for this national ambulance organisation.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
South Wales Central
Concerns raised1
Lack of specific guidance on classification of hotel rooms under the s136(1A) exception
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Fully consider the use of hotel rooms and section 136 under the Mental Health Act as an interim force safety issue.
Stated by South Wales PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Add a specific note on hotel rooms and section 136 to force guidance.
Stated by South Wales PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Include a specific note on hotel rooms and section 136 within force training.
Stated by South Wales PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Amend College guidance on using section 136 powers in hotel rooms.
Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Circulate a summary of the hotel-room section 136 issue to police force mental health leads across England and Wales.
Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Work with the Home Office to assess whether national guidance on section 136 and hotel rooms requires relevant changes.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.
Action
Keep police forces informed of developments concerning section 136 use in hotel rooms.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Further national guidance or legislative amendment on section 136 and hotel rooms is assigned to the Home Office and College of Policing.
Stated by South Wales PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Use of section 136 in hotel rooms cannot be mandated because there is no legal basis; officers must assess each case individually.
Stated by College of PolicingUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Carmarthenshire and Pembrokeshire
Concerns raised2
Inadequate criteria for identifying the most appropriate place of safety
Unclear responsibilities for transporting someone detained under Section 136 MHA 1983
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of clarity about police powers and role for Section 136 from-home cases
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review, revise and enhance multi-agency procedures through sessions involving all named partner organisations.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 28 December 2018.
Action
Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 28 December 2018.
Action
Consider better disseminating police powers, obligations and limitations to partner agencies through joint working initiatives.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 28 December 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Detention under section 136 was lawful because the person was found in the street, not a private dwelling.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Inadequate understanding of section 136 Mental Health Act and mental health issues among special police officers
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Continue mental-health training and partnership working through annual officer safety training.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 February 2019.
Action
Launch and operate a mental-health and wellbeing campaign providing training, awareness and support to officers.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 17 February 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Section 136 would not have assisted because it does not apply to people inside private dwellings.
Stated by Metropolitan Police ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to keep records of information provided verbally by Police Officers in the s.136 suite
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement recording of police verbal handovers on paper history sheets, with access for the assessing doctor and AMHP and subsequent upload to PARIS.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2018.
Action
Develop and display a laminated flowchart guiding s136 handover recording, documentation access and referral processes.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2018.
Action
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.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 February 2018.
East London
Concerns raised3
Failure to inform the on-call doctor of Section 136 assessment arrivals and outcomes
Inadequate medical staffing for Section 136 assessments
Failure to notify an AMHP of planned Section 136 assessments
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review the Goodmayes on-call doctors’ workload and undertake a follow-up audit of junior doctors’ workload and the impact of changes.
Stated by NELFT NHS NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Approval of proposed changes to the s136 form rests with the Metropolitan Police Service.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Changes to the s136 form cannot be given a realistic timescale because approval may be protracted and digital paperwork is planned.
Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures of dedicated Section 136 procedures, including information-sharing and consultation, understanding or application of powers, assessment and discharge, inter-agency policy coordination, notification, conveyance and place-of-safety arrangements.
