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
Distinct published reports
Individual concerns
33
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
82
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social 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
NHS trust25
Ministerial department7
English metropolitan district council6
Executive non-departmental public body5
Police force5
Integrated care board4
Type not available4
Health and social care service regulator3
English county council2
Independent healthcare provider2
London borough council2
Clinical commissioning group1
Domiciliary care provider1
English unitary authority1
Healthcare site1
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.
Manchester West
Concerns raised1
Failure to act on recommendations to consider Mental Health Act assessment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2018.
Birmingham and Solihull
Concerns raised1
Lack of early approved social worker involvement in 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to conduct detailed Section 136 assessments using relevant information from professional and non-professional sources
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.
Stated by NELFT NHS NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.
Stated by NELFT NHS NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Design a bespoke handover form with NELFT for use at the 136 suite.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Scan completed 136 paperwork, attach it to intelligence reports and store it on the internal server.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Hold a progress-review meeting on the bespoke handover form.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Inner South London
Concerns raised1
Inadequate standard of 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Action
Review the criteria for initial Approved Mental Health Professional training against the report’s findings.
Stated by Health and Care Professions CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
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.
Stated by Health and Care Professions CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Develop AMHP guidance on when relatives should be consulted during police-custody assessments.
Stated by Hampshire County Council and Portsmouth City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Publish AMHP guidance requiring direct scrutiny of police custody records and logs.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.
Stated by Hampshire County Council and Portsmouth City CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Review professional development opportunities for AMHPs conducting police-custody assessments.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Share the report’s learning with AMHP training providers, HCPC and other relevant professional training bodies.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Audit AMHP assessments routinely to ensure they meet the required standard.
Stated by Hampshire County Council and Portsmouth City CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Share learning from the case with relevant agencies to improve AMHP police-custody assessment practice.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing AMHP training criteria are considered appropriate and sufficient to require necessary mental health assessment skills.
Stated by Health and Care Professions CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Local Social Services Authorities are responsible for AMHP approval and ensuring approved AMHPs receive relevant annual training.
Stated by Health and Care Professions CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Rezone clients referred for a Mental Health Act assessment to Red until the assessment is completed.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The delay in arranging the Mental Health Act assessment was not caused by an unavailable Approved Mental Health Act Practitioner.
Stated by Oxleas NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Avon
Concerns raised1
Failure to carry out required Mental Health Act Assessments promptly when a bed is unavailable
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.
Inner North London
Concerns raised2
Failure to arrange Mental Health Act assessment when the responsible psychiatrist is unavailable
Delays in arranging urgent Mental Health Act assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Delaying the mental health assessment until the psychiatrist’s return was considered clinically reasonable because established cover arrangements were in place.
Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.
Stated by North London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Work with partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
Stated by British Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Provide cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Display the approved Section 136 flowchart prominently in the A&E department.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.
Stated by British Transport PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Health professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.
Stated by British Transport PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.
Stated by Royal Berkshire NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Failure to provide first-instance assessment by a healthcare professional qualified to make recommendations for section
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Liaison Psychiatry staff are experienced and trained, so the available assessment was considered the most appropriate despite no guaranteed 24/7 Section 12 assessment.
Stated by South West London and St George'S Mental Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The implication that only medically qualified staff can make accurate Liaison Psychiatry assessments is not accepted.
Stated by South West London and St George'S Mental Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
