Recurring concern

Unreliable police-hospital exchange of risk information during mental-health patient supervision

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First reported 7 Apr 2016•Latest report 3 Jun 2024

Definition

What this concern includes

Includes failures in the dedicated police-hospital process for sharing, obtaining, reviewing and using mental-health risk assessments and related safety information during police supervision, hospital observation or joint risk assessment of a patient, including written-assessment access, liaison about hospital hazards and communication of relevant risk factors.

Not included

Excludes generic inter-agency communication or information-sharing failures without a police-hospital mental-health patient-supervision context.
Excludes failures confined to the clinical quality of the mental-health assessment when the police-hospital information exchange itself is reliable.
Excludes police access to warrants, criminal records or other police information systems where no mental-health patient-supervision or police-hospital risk-information process is involved.
Excludes failures occurring after police and hospital staff have reliably exchanged the relevant risk information, including subsequent treatment, observation or operational decisions.

Reports: 3
Individual concerns: 4
Date range: 2016–2024
Stated actions: 8

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Home Office2

Association of Police and Crime Commissioners1

Birmingham and Solihull Mental Health NHS Foundation Trust1

College of Policing1

Greater Manchester Police1

National Police Chiefs’ Council1

NHS England1

Sussex Partnership NHS Foundation Trust1

Sussex Police1

West Midlands Police1

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust1

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.

3 Jun2024
Birmingham and Solihull
Concerns raised2
1. Failure to ensure police access to the written risk assessment
2. Failure to provide attending police officers with the written risk rating
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 2
1. Action
  Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
2. Action
  Establish a process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.
  Stated by West Midlands PoliceStated planned
Respondent positions 3
1. Position
  Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
  Stated by Home OfficeRedirects responsibility
2. Position
  Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.
  Stated by Home OfficeExisting arrangements considered sufficient
AI-generated summary

Tcherno Bari · 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

Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

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 ensure police access to the written risk assessment
Wider context from the report
“(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. ”
Source location
Tcherno Bari · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide attending police officers with the written risk rating
Wider context from the report
“(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. ”
Source location
Tcherno Bari · 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
Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.

Verbatim wording from the response
“At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

Source location
Response from BSMHFT
Page 1 · response
Published 6 June 2024
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 process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.

Verbatim wording from the response
“WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate.”

Source location
Response from West Midlands Police
Page 4 · response
Published 6 June 2024
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
Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.

Verbatim wording from the response
“Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
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
Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.

Verbatim wording from the response
“As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.”

Source location
Response from the Home Office
Page 1 · response
Published 6 June 2024
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
Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.

Verbatim wording from the response
“healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.”

Source location
Response from the Home Office
Page 2 · response
Published 6 June 2024
Open published response
28 Jan2022
West Sussex
Concerns raised1
1. Failure to discuss and confirm AWOL risk grading with police call-takers
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.
  Stated by Sussex PoliceStated in progress
2. Action
  Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.
  Stated by Sussex PoliceStated planned
3. Action
  Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
1. Action
  Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
AI-generated summary

Jack Stephen TAYLOR · 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

Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.

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 discuss and confirm AWOL risk grading with police call-takers
Wider context from the report
“2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”
Source location
Jack Stephen TAYLOR · 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
Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.

Verbatim wording from the response
“Developing a Missing Persons Template (including an action plan)”

Source location
2022-0029-Response-from-Sussex-Police_Published
Page 1 · response
Published 3 February 2022
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
Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.

Verbatim wording from the response
“Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.”

Source location
2022-0029-Response-from-Sussex-Police_Published
Page 2 · response
Published 3 February 2022
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
Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.

Verbatim wording from the response
“Developing a Missing Persons Template (including an action plan)”

Source location
2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022
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
Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.

Verbatim wording from the response
“Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.”

Source location
2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Page 2 · response
Published 3 February 2022
Open published response
7 Apr2016
Manchester West
Concerns raised1
1. Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop and finalise a joint Patient Under Escort Record with GMP, incorporating shared risk assessment and patient management information for escorted patients.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progress
2. Action
  Roll out training on using the Patient Under Escort Record to staff in A&E and assessment areas.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Responsibility for arrest, detention and supervision of hospital patients rests operationally with each police force’s chief officer.
  Stated by Home OfficeRedirects responsibility
AI-generated summary

Joyce Carney · 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

Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.

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 of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
Wider context from the report
“i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital. ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital. iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital. ”
Source location
Joyce Carney · 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
Develop and finalise a joint Patient Under Escort Record with GMP, incorporating shared risk assessment and patient management information for escorted patients.

Verbatim wording from the response
“Following the conclusion of Mrs Carney’s inquest, ████████ contacted ████████ (Detective Inspector) of GMP and it was agreed that both organisations would work jointly to address the actions outlined at points 1–3 above. The Trust already has a very good relationship with GMP and this would be utilised to formulate the required protocols, policies and procedures for the protection of patients, staff and visitors to the hospital.”

Source location
2016-0140-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
Page 2 · response
Published 7 April 2016
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
Roll out training on using the Patient Under Escort Record to staff in A&E and assessment areas.

Verbatim wording from the response
“The “Patient Under Escort Record” will be completed by the police officer when they attend the hospital site with the patient. The document will then be completed jointly by GMP and hospital staff throughout the course of the patient’s stay, and will remain with them until discharge. Upon discharge the document will become the property of GMP who will hold it on file to form part of their intelligence of that patient (should it be required in the future).”

Source location
2016-0140-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
Page 3 · response
Published 7 April 2016
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
Responsibility for arrest, detention and supervision of hospital patients rests operationally with each police force’s chief officer.

Verbatim wording from the response
“The arrest, detention and supervision of individuals by police whilst they are patients in hospital is an operational consideration for the chief officer of each police force. In carrying out their duties, the police should follow the College of Policing Authorised Professional Practice (APP) - Detention and Custody, which covers risk assessments when a person is detained in non-police custody settings, including hospitals. The College have also produced dedicated APP on risk, which focuses on planning for, and anticipating, risk in a variety of operational contexts.”

Source location
2016-0140-Response-by-Home-Office
Page 1 · response
Published 7 April 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure police access to the written risk assessment

Failure to provide attending police officers with the written risk rating

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Concerns raised1

Failure to discuss and confirm AWOL risk grading with police call-takers

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.4

Concerns raised1

Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Actions described in response 2

Respondent positions 3

Actions described in response 4

Actions described in response 2

Respondent positions 1