Recurring concern

Unreliable Mental Health Act assessment documentation

First to latest report 2 Nov 2018 — 27 May 2026

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
1

What this concern includes

Includes failures in documenting Mental Health Act assessments, including inaccurate patient information, incorrect or incomplete forms, missing required practitioner details, misleading assessment-status entries and other documentation defects that impair reliable assessment or statutory decision-making.

What is not included
  • Excludes failures in the substantive clinical quality, timeliness or outcome of a Mental Health Act assessment where the assessment documentation itself is not deficient.
  • Excludes generic clinical-record, communication or training deficiencies that are not specifically part of Mental Health Act assessment documentation.
  • Excludes documentation for other mental-health, safeguarding or statutory processes unless the assertion explicitly concerns Mental Health Act assessment documentation.
  • Excludes downstream detention, treatment, discharge or follow-up failures after the Mental Health Act assessment documentation has operated reliably.

Reports and published responses 4 reports

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

  1. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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

    Inclusion of inaccurate patient information in AMHP assessment documentation

    Wider context from the report

    “5. Abbi deteriorated significantly at the end of January 2022 and February 2022 requiring police to take Abbi to a place of safety due to her presentation and level of self-harm and suicidality that required a Mental Health Act assessment. Professional concerns were raised about inaccurate clinical information contained in the documentation from the Approved Mental Health Act Professional (AMHP) that were about another patient. Abbi made a video about the contents of this letter that reinforced her view that professionals did not care about her. Abbi received an apology about the inaccuracies in this AMHP assessment shortly before her death. ”

    Source location

    Abbigail Louise SMITH · Prevention of Future Deaths report
    Page 4 · 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 AMHP service falls outside the Trust’s remit because it is provided by Essex County Council.

    Verbatim wording from the response

    “Please note that the AMHP service is not provided by EPUT, this is provided by Essex County Council (ECC) who would be best placed to respond to this concern.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    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

    Essex County Council, which provides the AMHP service, is best placed to respond to concerns about that service.

    Verbatim wording from the response

    “Please note that the AMHP service is not provided by EPUT, this is provided by Essex County Council (ECC) who would be best placed to respond to this concern.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 5 · response
    Published 13 August 2026

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.

    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 Nearest Relative details on the MH 1

    Wider context from the report

    “I accepted independent expert evidence that the mental health act assessment had been thorough and appropriately concluded there were no grounds in law for detaining Callum. Additionally, I accepted evidence given by the clinicians that while NICE guidance did allow for short-term admissions to manage a period of crisis in a patient presenting with complex PTSD/EUPD, that was not indicated here. It was identified that the rationale for reaching that decision was not recorded in the notes. This is a matter I have taken up separately with those responsible for the AMHP. 1) It was accepted in evidence that, owing to the decisions made by Callum, there were only limited options available to the clinicians. Of note, an offer to have personal follow-up by one of the clinicians involved in the assessment through the HTT was rejected. Additionally, the possibility of prescribing additional Diazepam was correctly discounted once it became evident Callum was already sourcing illicitly more than could be prescribed safely. 2) Callum refused permission for his mother (described as his rock) to be informed of his imminent discharge. On her evidence, she had been (wrongly) advised by police that her son would be detained and was safe. There was no evidence that this decision by Callum was explored or tested by the clinicians – instead it simply appeared to have been accepted by the clinicians without further enquiry. The independent expert was of the view that in a situation like this, where the assessing team had very few ‘levers’ available to it, Callum’s mother was potentially one that could and should have been explored further. It was noted that GMC guidance allows for further enquiry, specifically that 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent. It was noted that the Nearest Relative’s details appeared not to have been completed on the MH 1. Again, this is a matter that has been brought to the attention of those responsible for the AMHP. ”

    Source location

    Callum James Hargreaves · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Cornwall and Isles of Scilly

    AI-generated summary

    Callum James Hargreaves · 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

    Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

    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 Nearest Relative details on the MH 1 form

    Wider context from the report

    “At inquest, the court heard from Gail Ashton who was the AMHP involved in the mental health act assessment conducted overnight on 19 & 20 January 2024. 1) One issue that arose was whether Callum presented with an imminent and significant risk of harm to justify a short-term admission into hospital as is provided for in NICE guidance. Ms Ashton said this was expressly discussed by the clinicians concerned. It was felt he was likely to be withdrawing and there were no resuscitation facilities available in Longreach. She also said the vulnerabilities of others on the ward needed to be considered all of which contributed to the decision not to detain Callum in hospital. She accepted that this rationale was not recorded in the notes. 2) Callum was asked whether he wanted his mother (who he described as his rock) notified of his discharge. He said that he did not. This was not tested or challenged where GMC guidance is that it may be appropriate to do so. The Nearest Relative details on the MH 1 form were not completed. The expert who reviewed the case felt there were ‘obvious gaps’ in the record keeping and that as Callum’s mother was one of the few levers available to the assessing team, Callum’s decision not to involve her should have been explored further. You may feel these omissions should be learned from when assessments are conducted in the future and, in particular, when notes of an assessment are subsequently recorded. ”

    Source location

    Callum James Hargreaves · 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

    Transfer Mental Health Act assessment recording from RIO to Mosaic to enable inclusion in the audit programme.

    Verbatim wording from the response

    “From the 14th of May 2025, the local authority has been proactively implementing a change in where Mental Health Act (MHA) assessments are recorded. This is a departure from the current practice of recording on the health database (RIO) to recording on the Adult Social Care database (Mosaic). This change will allow us to incorporate MHA assessments into our audit programme, thereby supporting improved quality and consistency in documentation and recording.”

    Source location

    Response from Cornwall Council (Care and Wellbeing)
    Page 3 · response
    Published 9 June 2025

    Open published response

  4. Manchester West

    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

    Failure to complete Mental Health Act assessment forms in the required format with the required practitioner information

    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

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