Recurring concern

Unreliable forensic psychiatric assessment pathways for criminal-justice placement decisions

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First reported 28 Dec 2014•Latest report 28 Jul 2017

Definition

What this concern includes

Includes failures of the dedicated forensic psychiatric assessment pathway for people subject to criminal-justice placement or transfer decisions, including timely assessment before custodial placement, independent-report commissioning and funding, specialist involvement, documented pathway guidance, and use of assessment findings to inform placement suitability.

Not included

  • Excludes general psychiatric assessment failures that are not specifically forensic or connected to a criminal-justice placement decision.
  • Excludes generic mental-health staffing, training, documentation or communication deficiencies unless they directly impair the forensic psychiatric assessment pathway.
  • Excludes routine clinical mental-health assessment, treatment or risk-management failures after placement where no forensic assessment or placement-decision concern is identified.
  • Excludes criminal-justice placement failures unrelated to obtaining or using forensic psychiatric assessment.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2017

First to latest report issue date

Stated actions
2

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.

Ministry of Justice3
HM Prison and Probation Service2
Central and North West London NHS Foundation Trust1
Cookham Wood Prison1
Greater Manchester Police1
HM Courts & Tribunals Service1
Home Office1
London Borough of Tower Hamlets1
Medway Youth Offending Team1
Ministry of Defence1
National Police Chiefs’ Council1
Oxleas NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Security Industry Authority1

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.

  1. London (City)

    AI-generated summary

    SARAH LYNNE REED · 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

    Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

    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 assign clear responsibility for obtaining fitness-to-plead reports

    Wider context from the report

    “(4) It was not clear on the evidence who took responsibility for obtaining the reports. The Court had ordered them, but the formal request for the first report, dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email from the Court to an administrative officer employed not by the prison but by the Central and North West London NHS Trust (CNWL) who worked from HMP Holloway. One month later, on 27 November 2015, a psychiatrist employed by CNWL in HMP Holloway wrote back to the Court, apologising for the delay and indicating that the request be directed not to CNWL but to the South London and Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no psychiatrist had yet agreed to prepare a report. ”

    Source location

    SARAH LYNNE REED · 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

    Route all external psychiatric-report requests promptly to the responsible consultant under the Standard Operating Procedure.

    Verbatim wording from the response

    “It now forms part of our Standard Operating Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 1 · response
    Published 1 August 2017

    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

    Review procedures for obtaining and providing psychiatric reports, including fitness-to-plead reports.

    Verbatim wording from the response

    “Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to ████████, Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re-issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has asked the Criminal Procedure Rule Committee to look at this issue with a view to providing greater certainty and clarity for the judiciary and court staff when dealing with psychiatric reports.”

    Source location

    2017-0208-Response-by-NOMS
    Page 2 · response
    Published 1 August 2017

    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

    HMPPS will clarify the process and procedure for providing psychiatric reports to courts.

    Verbatim wording from the response

    “We have had a discussion with Her Majesty’s Prison and Probation Service (HMPPS) who have agreed to clarify the process and procedure for the provision of psychiatric reports to Courts.”

    Source location

    2017-0238-Response-by-CNWL-NHS-Trust
    Page 1 · response
    Published 1 August 2017

    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

    Psychiatric-report practice directions and related rules are matters for the independent Criminal Procedure Rule Committee and Lord Chief Justice.

    Verbatim wording from the response

    “The working group will consider new practice directions, and in view of your concerns, it may decide to suggest new rules to govern the procedure on obtaining assessments of fitness to plead, and psychiatric reports for sentencing purposes. Even though listing is a judicial function, the working group may also recommend that new practice directions, or rules, should prescribe default time limits for steps to be taken and progress reviewed, subject to judicial adjustment in individual cases.”

    Source location

    2017-0208-Response-by-NOMS
    Page 2 · response
    Published 1 August 2017

    Open published response

  2. Manchester South

    AI-generated summary

    Paul Mc Guigan · 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

    Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.

    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 clear procedure and funding responsibility for independent forensic psychiatric reports

    Wider context from the report

    “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report, particularly in circumstances where a defendant is remanded on bail in the community. ”

    Source location

    Paul Mc Guigan · 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

    Judges or magistrates can commission independent psychiatric reports, with the Ministry of Justice providing procedural guidance for court-ordered reports.

    Verbatim wording from the response

    “You also comment on the need for a clear procedure to identify when an independent psychiatric report is needed, and to ensure that one is provided. In criminal cases, judges or magistrates can decide to commission an independent psychiatric report as part of the trial and sentencing processes. The cost of preparing such a report is met from central funds. It is frequently the case that the defence or prosecution will commission a psychiatric report, but this does not limit the powers of the court to order its own report. The Ministry of Justice has produced a good practice procedural”

    Source location

    2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
    Page 4 · response
    Published 12 May 2015

    Open published response

  3. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 forensic psychiatric assessment before custodial placement

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026