Recurring concern

Failure to ensure timely and appropriate Mental Health Act assessment

First to latest report 15 Apr 2014 — 13 Mar 2025

Reports that mention this concern
29
Times this concern has been raised
33
Stated actions linked to this concern
82

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.

What is 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 and published responses 29 reports

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

  1. Manchester West

    AI-generated summary

    William Myers · 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

    William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.

    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 act on recommendations to consider Mental Health Act assessment

    Wider context from the report

    “(4) On three occasions during 2015 other clinicians who encountered the attacker recommended that a Mental Health Act assessment be considered with a view to him being detained. These recommendations were not acted upon. Judgements made by Consultant psychiatrists were not acted upon, preferably by a second opinion in the least, but preferably by a Forensic Psychiatrist, as this has been verified by the benefit of hindsight, the attacker's propensity to violent conduct may well have been triggers by a Mental Health Act assessment. ”

    Source location

    William Myers · 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

    Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.

    Verbatim wording from the response

    “GMMH has ensured careful consideration is being given to the management of service users who go AWOL and the risk assessment process to be carried out prior to a multidisciplinary team discharging them.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 2 · response
    Published 14 March 2018

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Leah Abby Ratheram · 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

    Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

    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 early approved social worker involvement in Mental Health Act assessments

    Wider context from the report

    “3. The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this specialty at any early stage will affect the quality of mental health act assessments and the safety of patients. ”

    Source location

    Leah Abby Ratheram · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. East London

    AI-generated summary

    Peter Daniel Usher · Prevention of Future Deaths report

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

    Report summary

    Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to conduct detailed Section 136 assessments using relevant information from professional and non-professional sources

    Wider context from the report

    “1. The assessing team did not carry out a detailed assessment of Mr Usher, to include not only a personal assessment but also to obtain relevant clinical information from both professional and non-professional sources. This would have included information from the family and GP. There was also relevant information available to the paramedics and police that was not elicited by the assessing team. ”

    Source location

    Peter Daniel Usher · 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

    Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.

    Verbatim wording from the response

    “1, 2, 3, 4 | With emphasis on the requirement to comply with:”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 2 · response
    Published 19 February 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

    Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.

    Verbatim wording from the response

    “9 | To create a generic and secure nhs.net account for s136 suite, which would be monitored and used by the bleep holders to receive the collateral | OJ/VP/RK | 31.03.2017”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 4 · response
    Published 19 February 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

    Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.

    Verbatim wording from the response

    “1.1 – The s136 paperwork completed by officers on the street is Form 434. The form has two particular areas that by their description can create ambiguity when completing them. The first is towards the top where it has the words “Friends/Family” and a space adjacent to it for the officer to fill out. I believe this needs to be more specific and should be changed to “Next of Kin.” This will give the officers more clarity when completing the form and eliminating the potential risk of important information being missed. The second is further down and reads “Name of person handing over” then as above there is a space adjacent for the officer to complete. This leaves some doubt as to whether the person accepting responsibility needs to sign. Under the s136 Pathway it clearly states that a signature is required.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 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

    Design a bespoke handover form with NELFT for use at the 136 suite.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 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

    Scan completed 136 paperwork, attach it to intelligence reports and store it on the internal server.

    Verbatim wording from the response

    “provide the full details of what was recorded on the 136 but more of the circumstances of how police came to be in contact with the patient. This resulted in information from the form 434 being missed. To rectify this, a new system has been implemented whereby all paperwork is scanned and attached to the intelligence report. The digital paperwork is then stored on an internal server. This is important should we have occasion to deal with a repeat patient as it will enable us to gain a more accurate intelligence background to the individual.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 2 · response
    Published 19 February 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

    Hold a progress-review meeting on the bespoke handover form.

    Verbatim wording from the response

    “1.2 - In the interim period we have been working closely with North East London Foundation Trust (NELFT) and are in the process of designing a bespoke handover form to be held at the 136 suite. The theory behind this is to create a document that is specifically designed to identify information needed about the patient from the police to enable Goodmayes staff to provide the most appropriate care for the detained person.”

    Source location

    2016-0428-Response-by-Borough-Mental-Team
    Page 1 · response
    Published 19 February 2017

    Open published response

  4. Inner South London

    AI-generated summary

    Richard Walsh · 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 Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    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

    Inadequate standard of Mental Health Act assessments

    Wider context from the report

    “2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed. ”

    Source location

    Richard Walsh · 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

    Review the criteria for initial Approved Mental Health Professional training against the report’s findings.

    Verbatim wording from the response

    “We have given careful consideration to the findings of your report. We have a statutory responsibility to set criteria for initial Approved Mental Health Professional (AMHP) training and to approve training programmes. Having reviewed the criteria that we first published in 2013, we are confident that they continue to set out appropriate requirements for qualifying training, including requirements for those completing training to have acquired necessary skills in carrying out mental health assessments. However, as we only assumed responsibility for approving AMHP training in 2012, we are cognisant that the nurse involved in this case may well have undertaken training assessed against different requirements.”

    Source location

    2016-0377-Response-by-Health-Care-Professions-Council
    Page 1 · response
    Published 26 February 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

    Bring the report to the attention of local social services authorities through correspondence with Nicola Blackwood MP, in the context of their ongoing training obligations.

    Verbatim wording from the response

    “issues that you raise in your report. I have copied this letter to Nicole Blackwood MP to suggest that bringing your report to the attention of LSSA’s in the context of their ongoing training obligations might be an effective way of drawing attention to the issues that you raise.”

    Source location

    2016-0377-Response-by-Health-Care-Professions-Council
    Page 2 · response
    Published 26 February 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

    Develop AMHP guidance on when relatives should be consulted during police-custody assessments.

    Verbatim wording from the response

    “Due to the findings of the Inquest concerning the assessment conducted with Mr Walsh, HCC/ PCC will be developing AMHP practice guidance to support decision making for when a relative needs to be consulted about someone presenting in the Police Custody environment. Such AMHP guidance will highlight the necessity for such consultation on the grounds of the gravity of the presenting facts, the nature of the offence, the history of the individual, the availability and suitability of the relative, the views of the person subject to assessment and other relevant criteria.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 February 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

    Publish AMHP guidance requiring direct scrutiny of police custody records and logs.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the custody record or log.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 February 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

    Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.

    Verbatim wording from the response

    “The Coroner has highlighted the fact that the MHA assessors did not directly examine the ‘Detained Persons Medical Forms’.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 February 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

    Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.

    Verbatim wording from the response

    “The Coroner has highlighted that the Custody Officers and the MHA assessors never spoke.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 2 · response
    Published 26 February 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

    Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.

    Verbatim wording from the response

    “HCC/ PCC will be working with local NHS Provider Trusts and Hampshire Constabulary to review information sharing with the Police following joint assessment in Police Custody.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 February 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

    Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.

    Verbatim wording from the response

    “The standard of mental health act assessments is brought into question by the Coroner in light of the findings from this inquest. Certainly the conduct of each of the practitioners involved in this case is referred to separately.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 3 · response
    Published 26 February 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 professional development opportunities for AMHPs conducting police-custody assessments.

    Verbatim wording from the response

    “5.0 Training and Professional Development for AMHP staff when dealing with assessments in Police Custody”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 4 · response
    Published 26 February 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

    Share the report’s learning with AMHP training providers, HCPC and other relevant professional training bodies.

    Verbatim wording from the response

    “The findings of this report will also be shared with AMHP training providers, the Health and Social Care Professionals Council (HCPC) and other relevant professional training bodies to ensure that AMHP training and refresher training includes the learning from this report.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 4 · response
    Published 26 February 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

    Audit AMHP assessments routinely to ensure they meet the required standard.

    Verbatim wording from the response

    “PCC have audited ████████ assessments to ensure they are of a good standard. This practice is undertaken routinely within the Portsmouth AMHP service and will continue for all AMHPs. The manager of the service has been satisfied that ████████ work is of a high standard.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 5 · response
    Published 26 February 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

    Share learning from the case with relevant agencies to improve AMHP police-custody assessment practice.

    Verbatim wording from the response

    “HCC/ PCC will be seeking to share the learning from this case with relevant agencies to improve practice of the AMHP when assessing persons in police custody.”

    Source location

    2016-0377-Response-by-Hampshire-County-Council_Redacted
    Page 5 · response
    Published 26 February 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

    Existing AMHP training criteria are considered appropriate and sufficient to require necessary mental health assessment skills.

    Verbatim wording from the response

    “We have given careful consideration to the findings of your report. We have a statutory responsibility to set criteria for initial Approved Mental Health Professional (AMHP) training and to approve training programmes. Having reviewed the criteria that we first published in 2013, we are confident that they continue to set out appropriate requirements for qualifying training, including requirements for those completing training to have acquired necessary skills in carrying out mental health assessments. However, as we only assumed responsibility for approving AMHP training in 2012, we are cognisant that the nurse involved in this case may well have undertaken training assessed against different requirements.”

    Source location

    2016-0377-Response-by-Health-Care-Professions-Council
    Page 1 · response
    Published 26 February 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

    Local Social Services Authorities are responsible for AMHP approval and ensuring approved AMHPs receive relevant annual training.

    Verbatim wording from the response

    “Successful completion of an approved programme only makes an individual eligible to be approved to act as an AMHP. Under The Mental Health (Approved Mental Health Professionals) (Approval) (England) (England) Regulations 2008 approval to act as an AMHP rests with a Local Social Services Authority (LSSA) in England. The LSSA also has responsibility under the regulations for ensuring that the AMHPs they approve receive at least 18 hours of training per year relevant to their role. This is likely to be the most effective means of addressing the specific”

    Source location

    2016-0377-Response-by-Health-Care-Professions-Council
    Page 1 · response
    Published 26 February 2017

    Open published response

  5. Inner South London

    AI-generated summary

    Dr Debatra Sircar · 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

    Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment

    Wider context from the report

    “1. He was at risk from falls, associated with his alcohol abuse and had frequently presented in A&E department with symptoms and injuries associated with intoxication. He was unfit to be treated in the community. There appeared to be no sense of urgency in securing a bed. He was booked for a Mental Health Act (MHA) Assessment 11 days after it was advised he needed hospitalization, by which time he had died. The court was informed the delay related to the unavailability of a local authority MHA practitioner. ”

    Source location

    Dr Debatra Sircar · 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

    Rezone clients referred for a Mental Health Act assessment to Red until the assessment is completed.

    Verbatim wording from the response

    “Following our review, we have instigated the following change in practice:”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 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

    The delay in arranging the Mental Health Act assessment was not caused by an unavailable Approved Mental Health Act Practitioner.

    Verbatim wording from the response

    “The Trust acknowledges the long period of time it took to arrange a Mental Health Act assessment however this was not, despite what the court heard, due to the unavailability of an Approved Mental Health Act Practitioner (AMHP).”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  6. Avon

    AI-generated summary

    Mr. Rohan Fitzsimons · 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. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.

    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 carry out required Mental Health Act Assessments promptly when a bed is unavailable

    Wider context from the report

    “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG). (2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred. (3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available. (4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment. The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds. ”

    Source location

    Mr. Rohan Fitzsimons · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Sandra Bodrožič’ · 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

    Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such 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

    Failure to arrange Mental Health Act assessment when the responsible psychiatrist is unavailable

    Wider context from the report

    “2. The consultant psychiatrist treating Ms Bodrožič’ formed the view on the evening of 18 June 2014 that Ms Bodrožič’ should have a Mental Health Act assessment. However, the psychiatrist was going on holiday the following day and so decided to leave this until her return, rather than asking colleagues. ”

    Source location

    Sandra Bodrožič’ · Prevention of Future Deaths report
    Page 2 · 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

    Delays in arranging urgent Mental Health Act assessments

    Wider context from the report

    “3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral. However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June. Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday. The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”

    Source location

    Sandra Bodrožič’ · 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

    Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.

    Verbatim wording from the response

    “d) An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    Delaying the mental health assessment until the psychiatrist’s return was considered clinically reasonable because established cover arrangements were in place.

    Verbatim wording from the response

    “2. The Consultant Psychiatrist treating Ms Bodrozic had established a good rapport with her and her family and had made stringent efforts to engage Ms Bodrozic in her care. She felt that it was a reasonable clinical decision to carry out the MHA assessment following her period of leave. Whilst on leave, clinical cover arrangements were in place with another Consultant Psychiatrist, which is the usual procedure in order to continue to provide support to Ms Bodrozic and her family should she need arise. Ms Bodrozic brother contacted the team on 24th June expressing concerns about his sister’s mental health and following a home visit by the social worker, a referral for a MHA assessment was made.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    Open published response

  8. Berkshire

    AI-generated summary

    Stephen Peter Church · 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

    Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.

    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 appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment

    Wider context from the report

    “There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment. ”

    Source location

    Stephen Peter Church · 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

    Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.

    Verbatim wording from the response

    “Thames Valley Police were not directly involved in the original incident involving Mr Church, his detention under S136 Mental Health Act nor his subsequent care prior to his death on 13th May 2011. However, as the force lead in Mental Health for Thames Valley Police I take responsibility for co-ordinating the publication of an interagency joint working protocol for managing mental health in the Thames Valley Area. This protocol was subject to discussion during the inquest.”

    Source location

    2014-0331-Response-by-Thames-Valley-Police
    Page 1 · response
    Published 15 July 2014

    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

    Work with partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.

    Verbatim wording from the response

    “The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric liaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However, once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness. Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities.”

    Source location

    2014-0331-Response-by-Thames-Valley-Police
    Page 2 · response
    Published 15 July 2014

    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

    Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.

    Verbatim wording from the response

    “The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric liaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However, once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness. Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities.”

    Source location

    2014-0331-Response-by-Thames-Valley-Police
    Page 2 · response
    Published 15 July 2014

    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

    Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.

    Verbatim wording from the response

    “While British Transport Police have indicated that they are unable to be signatories to individual protocols as they are a National Force, Thames Valley Police will make every effort to ensure their awareness and understanding of the Thames Valley protocol.”

    Source location

    2014-0331-Response-by-Thames-Valley-Police
    Page 2 · response
    Published 15 July 2014

    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

    Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.

    Verbatim wording from the response

    “In summary, the break down in the chain of command is being addressed as a conduct issue and I am confident that there is no systemic failing in this area. With regards to the other concern highlighted, the BTP Manual of Guidance now includes the following:”

    Source location

    2014-0331-Response-by-British-Transport-Police
    Page 6 · response
    Published 15 July 2014

    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 cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.

    Verbatim wording from the response

    “There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 2 · response
    Published 15 July 2014

    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

    Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.

    Verbatim wording from the response

    “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 3 · response
    Published 15 July 2014

    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

    Display the approved Section 136 flowchart prominently in the A&E department.

    Verbatim wording from the response

    “In the meantime, the Royal Berkshire NHS Foundation Trust has finalised and approved a flowchart that will be prominently displayed in the A&E department. It is intended that the flowchart will be in place in the A&E department before 26 November 2014 and that staff will have received training with regards use of the flowchart and the S136 monitoring forms by the end of November 2014.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 4 · response
    Published 15 July 2014

    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

    Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.

    Verbatim wording from the response

    “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 3 · response
    Published 15 July 2014

    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

    Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.

    Verbatim wording from the response

    “2. The trust has a flowchart which identifies the steps that need to be taken from the point of admission to A&E and identifies the role of the psychological medicine service (PMS) at the Trust who will advise A&E on the management of the patient in the A&E Department. They will also check that AMHP has been called which was a particular area of concern.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 3 · response
    Published 15 July 2014

    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

    Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.

    Verbatim wording from the response

    “the patient to be assessed with either admission to the Trust with support from PMS or a transfer to a place of safety e.g. Prospect Park Hospital. The flowchart has been finalised and approved by the A&E Clinical Governance Team. The Royal Berkshire NHS Foundation Trust has also adopted the assessment forms for Section 136 monitoring from the mental health Trust so that the key information is gathered on admission and the nursing staff are able to identify whether the AMHP has been informed of the need for assessment at an early stage. There will be a further check made by the PMS who will advise the A&E staff regarding the management of the Section 136 patient in the A&E Department. PMS will also check whether the AMHP has been contacted. Copies of the assessment form for Section 136 will be sent to the RBH Mental Health Coordinator so that care can be audited.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 4 · response
    Published 15 July 2014

    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

    British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.

    Verbatim wording from the response

    “It was acknowledged at the Inquest that British Transport Police was not a signatory to the joint interagency protocol, but officers giving evidence accepted that they would try to work to the aims where possible. I endorse this aspiration but must highlight the impracticalities of British Transport Police being able to achieve this in every case.”

    Source location

    2014-0331-Response-by-British-Transport-Police
    Page 4 · response
    Published 15 July 2014

    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

    Health professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.

    Verbatim wording from the response

    “My view is supported by reference to a recent meeting of the Mental Health Partnership Board for London, which includes CEOs of the London Mental Health Trusts. At that meeting the question of whose role it was to call the AMHP following a S136 detention delivered a unanimous response; that it was the role of the health professionals as the police would not have access to up to date information. The Board has recently launched a new policy for S136 and S135 arrangements in”

    Source location

    2014-0331-Response-by-British-Transport-Police
    Page 4 · response
    Published 15 July 2014

    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

    A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.

    Verbatim wording from the response

    “In the meantime, the two senior consultants from the A&E department, ████████ and the Matron ████████ attended the inter-agency meeting at the Trust on 24 September and have taken the message back to the A&E department that they should be liaising with the PMS at the Trust who, although they will not take responsibility for the patient, will advise on their management and contacting the AMHP if that has not already been done. There is therefore a mechanism whereby the A&E staff will be aware that it is their responsibility to check that the AMHP has been contacted and if for any reason it is not done for the PMS to make sure that contact is made at the earliest opportunity.”

    Source location

    2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
    Page 4 · response
    Published 15 July 2014

    Open published response

  9. Inner West London

    AI-generated summary

    Mr Philip Anthony Dean · 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 Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

    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 first-instance assessment by a healthcare professional qualified to make recommendations for section

    Wider context from the report

    “(4) That such an extremely psychiatrically unwell patient does not have the benefit of assessment from a health care professional qualified to make recommendations for section at first instance, despite explicit referral for the same from the doctor who knows him best. ”

    Source location

    Mr Philip Anthony Dean · 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

    Liaison Psychiatry staff are experienced and trained, so the available assessment was considered the most appropriate despite no guaranteed 24/7 Section 12 assessment.

    Verbatim wording from the response

    “It has not been possible to identify any Accident and Emergency Department which runs a psychiatry service that has 24 hour 7 day a week presence of Section 12 approved doctors, and none where the Section 12 doctor would always do the assessment at first instance, unless the patient were being assessed in a police cell. Therefore it appears that Mr Dean received the most appropriate assessment available and this is comparable to other psychiatric services available elsewhere. The staff in Liaison Psychiatry are very experienced in carrying out mental health assessments and receive extensive training and ongoing supervision.”

    Source location

    2014-0172-Response
    Page 3 · response
    Published 15 April 2014

    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 implication that only medically qualified staff can make accurate Liaison Psychiatry assessments is not accepted.

    Verbatim wording from the response

    “The Liaison Psychiatry service is under-resourced compared to national guidance on staffing levels. In this regard, so are the majority of Liaison Psychiatry departments, and the under-resourcing is a matter primarily for the Trust’s commissioners, rather than a problem of resource allocation within the Trust. The Trust do have fewer Consultants than most London teaching hospital Liaison Psychiatry departments however the implication that only medically qualified staff can make accurate assessments is not accepted. An experienced and competent Band 7 nurse will do a much more robust assessment than a doctor who has been training in psychiatry for a few years and their assessments will be on a par with a senior doctor’s. An example of this was demonstrated last year when a Trust Consultant Psychiatrist provided a Coroner with data which showed a low”

    Source location

    2014-0172-Response
    Page 3 · response
    Published 15 April 2014

    Open published response

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

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Data last updated 7 September 2026