Recurring concern

Failure to ensure timely and appropriate Mental Health Act assessment

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First reported 15 Apr 2014•Latest report 13 Mar 2025

Definition

What this concern includes

Includes failures of the Mental Health Act assessment process, including suitably qualified first-instance assessment, prompt progression of recommendations, and appropriate action on recommendations to consider detention.

Not included

Excludes generic delays or clinical assessment failures not explicitly connected to Mental Health Act assessment.
Excludes unrelated referral, assessment, staffing, training, or communication deficiencies.
Excludes failures concerning other statutory or specialist assessments unless they are directly part of the Mental Health Act assessment process.

Reports: 29
Individual concerns: 33
Date range: 2014–2025
Stated actions: 82

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6

Birmingham City Council5

NHS England5

Birmingham and Solihull Mental Health NHS Foundation Trust4

Greater Manchester Mental Health NHS Foundation Trust4

Care Quality Commission3

Birmingham Women'S and Children'S NHS Foundation Trust2

East London NHS Foundation Trust2

Home Office2

Metropolitan Police Service2

Ministry of Justice2

NHS Birmingham and Solihull Integrated Care Board2

North London NHS Foundation Trust2

Oxleas NHS Foundation Trust2

Walsall Borough Council2

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.

5 Jan2022
Bedfordshire and Luton
Concerns raised1
1. Failure to provide AMHP assessment before discharge from section 136 detention
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
21 Jun2021
East Sussex
Concerns raised1
1. Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments
This report raised 3 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 2
1. Action
  Introduce dynamic risk assessment requirements, supervision safeguards, and access to current risk and clinical information through updated assessment forms and internal publication.
  Stated by East Sussex County CouncilStated completed
2. Action
  Identify difficulties in established processes for accessing and sharing relevant patient information with MHA Assessors.
  Stated by Sussex Partnership NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Established electronic, verbal and hard-copy information-sharing routes, supported by a 24-hour crisis team, provide access to relevant patient information.
  Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Rodney John DIXON · 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

Rodney John Dixon took his own life at home in Eastbourne on 15 July 2019 during the course of a Mental Health Act Assessment, following deterioration in his mental and physical health. The report raised concerns that training on Mental Health Act assessments, patient risk management and assessors was sub-optimal, and that independent clinicians needed reasonable access to patient data before assessments.

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 timely access to patient data for independent clinicians conducting Mental Health Act assessments
Wider context from the report
“Mental Health Act Assessments are conducted in East Sussex deploying clinicians from both ESCC and SPT and independent clinicians such as psychiatrists. The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments needs to be ensured prior to assessments. ”
Source location
Rodney John DIXON · Prevention of Future Deaths report
Page 1 · 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
Introduce dynamic risk assessment requirements, supervision safeguards, and access to current risk and clinical information through updated assessment forms and internal publication.

Verbatim wording from the response
“(1) Leon Gooding (Head of Adult Social Care) hosted a meeting with all the Council’s Approved Mental Health Practitioners (AMHPs) to discuss the issues arising from this case. During the meeting, It was agreed that the client in cases similar to that of Mr. Dixon should not be left unsupervised unless assessed to be of low risk. The Council’s Mental Health Act referral and Risk Assessment Forms have been updated. They include a new section entitled “dynamic risk assessment”.”

Source location
Response from East Sussex County Council
Page 2 · response
Published 28 June 2021
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
Identify difficulties in established processes for accessing and sharing relevant patient information with MHA Assessors.

Verbatim wording from the response
“The Crisis Resolution Home Treatment Team are the Trust team that are available to support the MHA Assessors with access to relevant patient information and are available 24 hrs a day. However, I recognise your concerns and, therefore, have asked the Deputy Chief Nurse, when she discusses matters with ESCC, to identify if there are any difficulties with these established access processes that need to be addressed.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 28 June 2021
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
Established electronic, verbal and hard-copy information-sharing routes, supported by a 24-hour crisis team, provide access to relevant patient information.

Verbatim wording from the response
“Regarding accessibility of relevant patient clinical information, I would like to assure you that it has long been the case that ESCC have had access to the Trust’s electronic record system, Carenotes, to enable patient information to be accessible to them. The expectation is that the ESCC AMHP would access the necessary information and appropriately share it with any independent s.12 doctor who does not have access. In addition, it has been the working practice for many years that the Trust also shares information verbally and/or by providing hard copies of relevant patient records to AMHPs and to independent s.12 doctors, as needed. This further communication route facilitates the sharing of information if, for any reason, electronic access to Carenotes is not achievable.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 28 June 2021
Open published response
29 Jan2020
East London
Concerns raised1
1. Delays of 14 days in securing mental health act assessments
This report raised 5 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 3
1. Action
  Liaise with local-authority partners to address delays in community Mental Health Act assessments.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Monitor community Mental Health Act assessment waiting times through the Mental Health Law Committee under the CQC action plan.
  Stated by North London NHS Foundation TrustStated completed
3. Action
  Update policies and procedures guiding police preparation and planning of section 135 Mental Health Act warrants.
  Stated by Metropolitan Police ServiceStated completed
Respondent positions 4
1. Position
  Local organisations, including police, local authorities and NHS services, are responsible for systems ensuring Section 135 actions occur swiftly.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Mental Health Act assessments are coordinated and carried out by the Local Authority’s AMHP service, not the Trust.
  Stated by North London NHS Foundation TrustRedirects responsibility
2. Position
  The relevant Mental Health Trust must explain delays in securing Mental Health Act warrants because the warrant application process is not conducted by police.
  Stated by Metropolitan Police ServiceRedirects responsibility
3. Position
  Local Authorities are responsible for arranging Mental Health Act assessments and ensuring sufficient Approved Mental Health Professionals are available.
  Stated by Metropolitan Police ServiceRedirects responsibility
AI-generated summary

Thiago Araujo · 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

Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.

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
Delays of 14 days in securing mental health act assessments
Wider context from the report
“5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks. Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable. ”
Source location
Thiago Araujo · 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
Liaise with local-authority partners to address delays in community Mental Health Act assessments.

Verbatim wording from the response
“The AMHP service, which coordinates and carries out assessments under the Mental Health Act, is a local authority service, although physically based on Trust premises. The Trust has liaised with our local authority partners in regard to this important issue and we can report as follows:”

Source location
2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
Page 3 · response
Published 4 May 2021
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
Monitor community Mental Health Act assessment waiting times through the Mental Health Law Committee under the CQC action plan.

Verbatim wording from the response
“The average wait for a community assessment at the moment is around 14 days. In February 2020 when the incident took place the average wait time was closer to 18 days, so we are seeing some improvement but acknowledge further is required. This issue is part of our CQC action plan and ongoing monitoring is in place as part of this via our Mental Health Law Committee.”

Source location
2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
Page 3 · response
Published 4 May 2021
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
Update policies and procedures guiding police preparation and planning of section 135 Mental Health Act warrants.

Verbatim wording from the response
“The current MPS policies and procedures governing the framework, operational and tactical guidance for Police Officers and Staff, were updated in May 2020. The guidance specifically assists Basic Command Unit Operations’ Room Staff involved in the preparation and planning of warrants under section 135(1) and 135(2) of the Mental Health Act with responding to AMHP requests.”

Source location
2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
Page 2 · response
Published 4 May 2021
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
Local organisations, including police, local authorities and NHS services, are responsible for systems ensuring Section 135 actions occur swiftly.

Verbatim wording from the response
“In relation to the concerns you raise about the use of Section 135(1) of the Mental Health Act, it is not clear from your report whether the delay professionals expected lay in the magistrate issuing a Section 135(1) warrant; in securing an approved mental health practitioner and a doctor to be present when the officer actions the warrant; or in securing two doctors to carry out an assessment under the Act after the patient has been taken to hospital. However, we expect local organisations, including the police, local authority services, and the NHS, to have robust systems and agreements in place to ensure these actions are carried out swiftly.”

Source location
2021-0132-Response-from-Dept.-of-Health-and-Social-Care-Redacted.pdf
Page 1 · response
Published 4 May 2021
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
Mental Health Act assessments are coordinated and carried out by the Local Authority’s AMHP service, not the Trust.

Verbatim wording from the response
“The AMHP service, which coordinates and carries out assessments under the Mental Health Act, is a local authority service, although physically based on Trust premises. The Trust has liaised with our local authority partners in regard to this important issue and we can report as follows:”

Source location
2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
Page 3 · response
Published 4 May 2021
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 relevant Mental Health Trust must explain delays in securing Mental Health Act warrants because the warrant application process is not conducted by police.

Verbatim wording from the response
“Any delay in securing a Mental Health Act warrant and subsequent assessment would be for the relevant Mental Health Trust to respond to in detail, as the warrant application process is not conducted by the MPS. However, I believe it would assist HM Coroner, by explaining the processes in place for securing police assistance in such matters.”

Source location
2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
Page 2 · response
Published 4 May 2021
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
Local Authorities are responsible for arranging Mental Health Act assessments and ensuring sufficient Approved Mental Health Professionals are available.

Verbatim wording from the response
“The Mental Health Act 1983 (Codes of Practice), stipulate that responsibilities for arranging Mental Health Act Assessments lie with Local Authorities, who must ensure there are sufficient Approved Mental Health Professionals (AMHP) available to carry out their roles under the Act. This includes assessing patients to decide whether an application for detention should be made.”

Source location
2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
Page 2 · response
Published 4 May 2021
Open published response
15 Jan2020
Manchester West
Concerns raised1
1. Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Daniel Jeffrey Moran · 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

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

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 recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
Wider context from the report
“4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale. ”
Source location
Daniel Jeffrey Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Sep2019
Birmingham and Solihull
Concerns raised2
1. Delays in organising timely mental health assessments
2. Failure to place patients on the recommended Mental Health Act section
This report raised 3 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 8
1. Action
  Increase AMHP staffing and provide additional staffing capacity when the duty AMHP requires assistance.
  Stated by Walsall Borough CouncilStated completed
2. Action
  Provide AMHP on-call assistance to support the duty AMHP whenever needed.
  Stated by Walsall Borough CouncilStated completed
3. Action
  Provide a manager on duty or on call at all times to assist staff.
  Stated by Walsall Borough CouncilStated completed
1. Action
  Develop a procedure requiring Walsall hospitals to notify the Council promptly when any patient may require assessment.
  Stated by Walsall Borough CouncilStated in progress
2. Action
  Develop a procedure to monitor assessments undertaken by other authorities and trigger Walsall action when delays appear likely.
  Stated by Walsall Borough CouncilStated in progress
3. Action
  Develop a procedure for staff to request information promptly from other authorities and NHS services when Walsall assessment may be required.
  Stated by Walsall Borough CouncilStated in progress
4. Action
  Develop cross-agency practices for assessing patients from other authorities, including arrangements with neighbouring authorities.
  Stated by Walsall Borough CouncilStated in progress
5. Action
  Develop a procedure ensuring assessments are completed promptly and staff assistance is provided when necessary.
  Stated by Walsall Borough CouncilStated planned
Respondent positions 3
1. Position
  Delays in arranging assessment, detention choice and Walsall Council’s investigation were matters for the other identified bodies to address.
  Stated by Priory GroupRedirects responsibility
1. Position
  Walsall Council disputes that it should have known about the detention or assessment need before being contacted by another authority.
  Stated by Walsall Borough CouncilDisputes the concern
2. Position
  Birmingham City Council, as the patient’s home authority, was responsible for arranging the assessment and initially agreed to undertake it.
  Stated by Walsall Borough CouncilRedirects responsibility
AI-generated summary

Gurdeep Singh Dundhal · 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

Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.

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
Delays in organising timely mental health assessments
Wider context from the report
“1. There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was undertaking the assessment between Walsall MBC and Birmingham City Council. In addition there was a lack of resources to enable the assessment to be carried out in a timely manner. This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire. ”
Source location
Gurdeep Singh Dundhal · 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 place patients on the recommended Mental Health Act section
Wider context from the report
“3. When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3. No explanation was available for this. Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation. ”
Source location
Gurdeep Singh Dundhal · 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
Increase AMHP staffing and provide additional staffing capacity when the duty AMHP requires assistance.

Verbatim wording from the response
“The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.”

Source location
2019-0294-Response-by-Walsall-Council
Page 4 · response
Published 1 November 2019
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
Provide AMHP on-call assistance to support the duty AMHP whenever needed.

Verbatim wording from the response
“There has been an increase in AMHPs employed by Walsall Council. There have been changes in working practices to avoid the previous practice of an AMHP being on duty for 12 hours followed by a period of being on call for a further period of 12 hours. In addition to that AMHPs will be available on call to assist the AMHP on duty whenever that may be needed. There will also be a manager on duty or on call, and thus available to provide assistance, at all times of the day and night. Walsall Council has opened discussions with its neighbouring authorities to formalise practices of asking neighbouring authorities to carry out reviews within the borough of Walsall. There will be a procedure for staff to ensure that the assessment has been carried out and completed in good time and for staff to be called on to assist if need be.”

Source location
2019-0294-Response-by-Walsall-Council
Page 5 · response
Published 1 November 2019
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
Provide a manager on duty or on call at all times to assist staff.

Verbatim wording from the response
“The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.”

Source location
2019-0294-Response-by-Walsall-Council
Page 4 · response
Published 1 November 2019
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
Develop a procedure requiring Walsall hospitals to notify the Council promptly when any patient may require assessment.

Verbatim wording from the response
“The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.”

Source location
2019-0294-Response-by-Walsall-Council
Page 4 · response
Published 1 November 2019
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
Develop a procedure to monitor assessments undertaken by other authorities and trigger Walsall action when delays appear likely.

Verbatim wording from the response
“A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.”

Source location
2019-0294-Response-by-Walsall-Council
Page 4 · response
Published 1 November 2019
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
Develop a procedure for staff to request information promptly from other authorities and NHS services when Walsall assessment may be required.

Verbatim wording from the response
“A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.”

Source location
2019-0294-Response-by-Walsall-Council
Page 4 · response
Published 1 November 2019
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
Develop cross-agency practices for assessing patients from other authorities, including arrangements with neighbouring authorities.

Verbatim wording from the response
“The review has also opened discussions with a partner authority to consider improvements that can be made.”

Source location
2019-0294-Response-by-Walsall-Council
Page 1 · response
Published 1 November 2019
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
Develop a procedure ensuring assessments are completed promptly and staff assistance is provided when necessary.

Verbatim wording from the response
“There has been an increase in AMHPs employed by Walsall Council. There have been changes in working practices to avoid the previous practice of an AMHP being on duty for 12 hours followed by a period of being on call for a further period of 12 hours. In addition to that AMHPs will be available on call to assist the AMHP on duty whenever that may be needed. There will also be a manager on duty or on call, and thus available to provide assistance, at all times of the day and night. Walsall Council has opened discussions with its neighbouring authorities to formalise practices of asking neighbouring authorities to carry out reviews within the borough of Walsall. There will be a procedure for staff to ensure that the assessment has been carried out and completed in good time and for staff to be called on to assist if need be.”

Source location
2019-0294-Response-by-Walsall-Council
Page 5 · response
Published 1 November 2019
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
Delays in arranging assessment, detention choice and Walsall Council’s investigation were matters for the other identified bodies to address.

Verbatim wording from the response
“You will appreciate that in respect of points 1, 3 and 4, PGH is not in a position to comment and that (i) any delays in arranging the MHA assessment; (ii) the use of Section 2 rather than a Section 3 detention on admission; and (iii) the failure by Walsall MBC to undertake an investigation are matters for the other interested persons noted above to address.”

Source location
2019-0294-Response-by-The-Priory
Page 1 · response
Published 1 November 2019
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
Walsall Council disputes that it should have known about the detention or assessment need before being contacted by another authority.

Verbatim wording from the response
“Walsall Council points out that it did not know that Gurdeep Singh Dundhal was in Lakeside View Hospital and needed to be assessed, and could not reasonably have been expected to have known that, until after more than 24 hours had elapsed since his detention under s. 5 (2) of the Mental Health Act 1983 when it was contacted about him. That contact came from Birmingham City Council in a telephone call. During that telephone conversation Birmingham City Council agreed to carry out the assessment of Gurdeep Singh Dundhal. Walsall Council had no cause for concern about the assessment being carried out until Saturday 13 April 2019 at 17:35 when it was contacted by Lakeside View who said that the assessment had still not been carried out.”

Source location
2019-0294-Response-by-Walsall-Council
Page 3 · response
Published 1 November 2019
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
Birmingham City Council, as the patient’s home authority, was responsible for arranging the assessment and initially agreed to undertake it.

Verbatim wording from the response
“Gurdeep Singh Dundhal was detained under s.5 (2) of the Mental Health Act 1983 at 11.50am on Thursday 11 April 2019. Walsall Council was not then told of his detention. Lakeside View Hospital, where Gurdeep Singh Dundhal was detained, had informed Birmingham City Council of his detention. This was not only an understandable move but a sensible one. Lakeside View Hospital had been treating Gurdeep Singh Dundhal since mid-March 2019. He had been referred there by the Mental Health Team from Birmingham City Council who had been providing his care in the community for approximately 3 years. As his home authority it was Birmingham City Council which was responsible, in March 2019, for arranging his detention under s.2 of the Mental Health Act 1983 for assessment.”

Source location
2019-0294-Response-by-Walsall-Council
Page 1 · response
Published 1 November 2019
Open published response
22 Jul2019
Birmingham and Solihull
Concerns raised1
1. Unavailability of approved Mental Health practitioners for Mental Health Act assessments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the current AMHP service-delivery model to improve AMHP availability.
  Stated by Birmingham City CouncilStated in progress
2. Action
  Review the improvement plan addressing system-wide issues affecting AMHP services.
  Stated by Birmingham City CouncilStated completed
3. Action
  Hold a workshop with the Mental Health Trust and AMHP service to improve joint working.
  Stated by Birmingham City CouncilStated planned
Respondent positions 3
1. Position
  The Coroner stated that completing the requested mental health assessment would not have changed the outcome.
  Stated by Birmingham City CouncilDisputes the concern
1. Position
  Existing referral screening and prioritisation treated hospital patients as in a place of safety, prioritising community and police-custody cases.
  Stated by Birmingham City CouncilExisting arrangements considered sufficient
2. Position
  Assessment times depend on partner-agency resources, which the AMHP coordinates but lacks authority to prioritise.
  Stated by Birmingham City CouncilRedirects responsibility
AI-generated summary

Richard Patrick Carlon · 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

Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.

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 approved Mental Health practitioners for Mental Health Act assessments
Wider context from the report
“1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments. ”
Source location
Richard Patrick Carlon · Prevention of Future Deaths report
Page 1 · 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
Review the current AMHP service-delivery model to improve AMHP availability.

Verbatim wording from the response
“AMHP availability In response to the ongoing issue of AMHP availability leading to delays in assessments, below is a brief synopsis of the process adopted and the work currently being undertaken by BCC to bring about improvements around the availability of the AMHP service.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 2 · response
Published 18 October 2019
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 the improvement plan addressing system-wide issues affecting AMHP services.

Verbatim wording from the response
“A project board meeting which serves as a governance body for the improvement work around the AMHP service in Birmingham was held on 11th September 2019. The board reviewed the plan providing solutions to system wide issues impacting the work of the AMHPs. It should be reiterated that the review identified a total of 60 areas for improvement and 20 of these were related to whole systems partnership working.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 2 · response
Published 18 October 2019
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
Hold a workshop with the Mental Health Trust and AMHP service to improve joint working.

Verbatim wording from the response
“The other area that was agreed on was a workshop being held to agree improved joint working between the Mental Health Trust and the AMHP service. This workshop will be set up very shortly. The board has agreed to meet on a monthly basis and will become the vehicle for overseeing the improvement work.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 3 · response
Published 18 October 2019
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 Coroner stated that completing the requested mental health assessment would not have changed the outcome.

Verbatim wording from the response
“The matter of concern relating to BCC was that no Approved Mental Health Professional (AMHP) was available to make the requested Mental Health Act Assessment (MHAA) of Mr Carlon in the early hours of the 14th November 2018, the Coroner having been told that this was an ongoing problem and was delaying assessments. It is understood that in delivering her findings of fact, the Coroner stated in the inquest that had the MHAA taken place it would not have changed the outcome for Mr Carlon.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 1 · response
Published 18 October 2019
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
Existing referral screening and prioritisation treated hospital patients as in a place of safety, prioritising community and police-custody cases.

Verbatim wording from the response
“• All MHAA referrals are screened and prioritised and as Mr Carlon was in a hospital setting therefore deemed to be in a place of safety. In situations like this where the service is in receipt of multiple referrals the priority would always be those in the community or those individuals in police custody presenting a risk to themselves and the public.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 1 · response
Published 18 October 2019
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
Assessment times depend on partner-agency resources, which the AMHP coordinates but lacks authority to prioritise.

Verbatim wording from the response
“The coordination role involves the AMHP being multi agency dependant. It is this that will often impact on time scales for MHAAs being completed rather than availability of AMHPs who may well be coordinating MHAAs and chasing up partner agencies. The availability of partner agency resources as opposed to AMHP prioritisation decisions by AMHPs and partners, can involve people undergoing more than one MHAA before resources become available to allow a suitable outcome.”

Source location
2019-0287-Response-by-Birmingham-City-Council
Page 2 · response
Published 18 October 2019
Open published response
1 Jul2019
Black Country
Concerns raised1
1. Failure to coordinate multidisciplinary review and mental health act assessment when considering hospital admission
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Peter Lawrence (PL) · 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 Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.

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 coordinate multidisciplinary review and mental health act assessment when considering hospital admission
Wider context from the report
“4. A decision to admit to hospital under the mental health act following concerns being raised about self-care and disengagement could potentially have followed a coordinated MDT review and mental health act assessment and prevented deterioration in his mental health. ”
Source location
Mr Peter Lawrence (PL) · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Apr2019
Suffolk
Concerns raised1
1. Failure to undertake a formal mental health act assessment
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.
Respondent positions 1
1. Position
  The response does not identify a stage requiring mental health legislation assessment; engagement with offered care supported least restrictive treatment.
  Stated by Norfolk and Suffolk NHS Foundation TrustDisputes the concern
AI-generated summary

Anthony Hayward BUCKINGHAM · 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

Anthony Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.

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 undertake a formal mental health act assessment
Wider context from the report
“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”
Source location
Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report
Page 1 · 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 response does not identify a stage requiring mental health legislation assessment; engagement with offered care supported least restrictive treatment.

Verbatim wording from the response
“The report doesn't identify at which stage of care a request for a mental health act assessment may have been appropriate. Following the initial assessment, Anthony was an assessment and was engaged with the appointments and telephone calls offered. This was in keeping with the principle of least restrictive treatment.”

Source location
2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019
Open published response
2 Nov2018
Manchester West
Concerns raised1
1. Sub-optimal Mental Health Act assessment performance
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Karl Qolf Jamil Englemak Cassimjee · 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

Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

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
Sub-optimal Mental Health Act assessment performance
Wider context from the report
“1. Brief circumstances of matter of concern a. A Mental Health Act assessment had been completed without a collateral history being obtained (including Clatterbridge Hospital); b. The assessment completed by the Specialist Registrar was entered on the form ‘Amongst systems’ in the incorrect format with no South Practitioner; c. The assessment, as recorded by the Registrar was accepted to be sub-optimal; d. The risk assessment has no clear formulation of risk and no evidence of collaborative safety planning with the deceased (that is to say, clear evidence that the advice was to means to take in the event of a deterioration in his condition from discharge to being seen by the Mental Health Home Treatment Team. e. It is unclear from patient records as to what information the deceased and/or the British Transport Police (who were tasked with the responsibility of considering the feedback to the response about contact with the MHTT or what action to be taken in the event of a deterioration in the interim). f. A Mental Health Nurse recorded a substantial and detailed history given to her by the deceased setting out the full extent of his florid delusions and paranoid thoughts that to have been fully and adequately properly evaluated by the Specialty Registrar, to the extent that the nurse expressed extreme surprise that the Registrar had not shown the required concern, and Mental Health Act detention where being no means within the operational procedures in place for the nurses concerns to be taken into account. ”
Source location
Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Nov2018
Milton Keynes
Concerns raised1
1. Failure to complete a full Mental Health Act assessment by a psychiatrist before discharge
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.
AI-generated summary

Colette Denise Vivienne Jean DUNN · 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

Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.

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 complete a full Mental Health Act assessment by a psychiatrist before discharge
Wider context from the report
“1. During the course of the evidence it was clear that prior to discharge from the hospital a full Mental Health Act assessment by a psychiatrist should have been carried out before the decision was taken to discharge Ms Dunn, particularly as the police officers were expressing their concerns to the staff that Ms Dunn had indicated that once she had left the hospital it was her intention to kill herself and indicated that she would tell the staff what they wanted to hear in order to secure her discharge. ”
Source location
Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide AMHP assessment before discharge from section 136 detention

Concerns raised1

Lack of timely access to patient data for independent clinicians conducting Mental Health Act assessments

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Delays of 14 days in securing mental health act assessments

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria

Concerns raised2

Delays in organising timely mental health assessments

Failure to place patients on the recommended Mental Health Act section

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.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Unavailability of approved Mental Health practitioners for Mental Health Act assessments

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

Actions described in response 2

Respondent positions 1

Actions described in response 3

Respondent positions 4

Actions described in response 8

Respondent positions 3

Actions described in response 3