Concerns raised 1
Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
View source
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AI-generated summary
Patricia Genders · 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
Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
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× 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 a safe lawful detention pathway for people who cannot be held under s.3 at the hospital
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all ). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Source location Patricia Genders · Prevention of Future Deaths report
Open source report
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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 Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
Verbatim wording from the response “Colleagues in NHS England’s South East Region have confirmed that, to improve their ability to respond to patients in mental health crisis and ensure the needs of mental health patients are met in an appropriate environment, the NHS has committed to establish Mental Health Emergency Departments (MHEDs), also described as Crisis Assessment Centres (CACs), which will be co-located with Type 1 Emergency Departments. They aim to offer calm, therapeutic settings and ensure timely onward connection into mental health inpatient provision or into broader community services.” Source location Response from NHS England
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Epsom and St Helier University Hospitals NHS Trust NHS Southwest London Integrated Care Board Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Surrey and Borders Partnership NHS Foundation Trust
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
View source
Department of Health and Social Care
Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
View source
Department of Health and Social Care
Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
View source
Department of Health and Social Care
Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
View source
Department of Health and Social Care
Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
View source See 2 more actions
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AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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× 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 lawful Mental Health Act detention safeguards and Responsible Clinician oversight
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department . There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 . In addition, they do not have a Responsible Clinician .
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Source location Tracey Ostler · Prevention of Future Deaths report
Open source report
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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 Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Verbatim wording from the response “Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
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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 Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
Open published response
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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 further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
Open published response
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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 Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
Open published response
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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 further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
Verbatim wording from the response “We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice.” Source location Response from Department for Health and Social Care
Open published response
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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 acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.
Verbatim wording from the response “A person can only be detained once admitted to an acute hospital bed. While the Trust’s position is that steps should be taken to ensure an appropriate legal framework, the decision to detain to an acute hospital bed lies with the management of the acute hospital. This is not an issue unique to Surrey; one of the proposed amendments to the Mental Health Bill is to allow people to be detained in emergency departments in recognition of the current gap in legislation.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
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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 Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Verbatim wording from the response “Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.” Source location Response from Epsom General Hospital
Open published response
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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 Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Verbatim wording from the response “NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.” Source location Response from Epsom General Hospital
Open published response
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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 Clinical matters fall outside the commissioning organisation’s remit.
Verbatim wording from the response “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.” Source location Response from NHS South West London Integrated Care Board
Open published response
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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 Clinical matters are the responsibility of the relevant Trusts.
Verbatim wording from the response “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.” Source location Response from NHS South West London Integrated Care Board
Open published response
18 Feb 2025 Ronald Bainborough · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Delays in obtaining Magistrates Court hearings for s135(1) warrant applications View source Lack of an official fast-track procedure for s135(1) warrants View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Courts & Tribunals Service Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Metropolitan Police Service
Review the corporate section 135 warrant process and incorporate matters raised in the report and identified learning.
View source
HM Courts & Tribunals Service
Prioritise mental health warrant applications as priority-one work when allocating court time.
View source
HM Courts & Tribunals Service
Provide remote mental health warrant applications with online self-service booking.
View source
HM Courts & Tribunals Service
Provide two separate remote warrant sessions daily on weekdays, with capacity exceeding typical demand.
View source
HM Courts & Tribunals Service
Maintain an open-door process allowing applicants to obtain immediate access to a courtroom for warrant applications.
View source
HM Courts & Tribunals Service
Provide out-of-hours access to the Judiciary for urgent mental health warrant applications seven days a week.
View source
HM Courts & Tribunals Service
Provide a central team and access routes through London magistrates’ courts for urgent warrant applications.
View source
HM Courts & Tribunals Service
Provide practitioners with guidance describing booking arrangements for non-urgent, urgent and out-of-hours applications.
View source See 5 more actions
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AI-generated summary
Ronald Bainborough · 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
Ronald Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting assessment.
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× 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 obtaining Magistrates Court hearings for s135(1) warrant applications
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Source location Ronald Bainborough · Prevention of Future Deaths report
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 Lack of an official fast-track procedure for s135(1) warrants
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Source location Ronald Bainborough · Prevention of Future Deaths report
Open source report
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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 corporate section 135 warrant process and incorporate matters raised in the report and identified learning.
Verbatim wording from the response “The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this PFD report and learning identified will be incorporated into this.” Source location Response from MPS
Open published response
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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 Prioritise mental health warrant applications as priority-one work when allocating court time.
Verbatim wording from the response “1) Listing is a judicial function and responsibility and arrangements for the operation of court lists are agreed with the judiciary and implemented by HMCTS. Arrangements for s.135 MHA warrants fall into these arrangements.” Source location Response from HMCTS
Open published response
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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 remote mental health warrant applications with online self-service booking.
Verbatim wording from the response “Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue.” Source location Response from HMCTS
Open published response
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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 two separate remote warrant sessions daily on weekdays, with capacity exceeding typical demand.
Verbatim wording from the response “The search warrant remote process was specifically designed to meet the needs and demands of the 32 London boroughs it serves. Since the inception of the remote process HMCTS has provided daily access to two separate, remote warrant sessions through Monday - Friday. The system is set up as an online self service, which means applicants can select hearing dates and times for their applications. Where sessions have been booked in advance, it is not unusual and indeed is commonplace for applicants to cancel slots, those slots are released back to the booking in system.” Source location Response from HMCTS
Open published response
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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 Maintain an open-door process allowing applicants to obtain immediate access to a courtroom for warrant applications.
Verbatim wording from the response “Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue.” Source location Response from HMCTS
Open published response
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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 out-of-hours access to the Judiciary for urgent mental health warrant applications seven days a week.
Verbatim wording from the response “Additionally, the court provides a daily out of hours service for such applications, ensuring that the ability to apply for a mental health warrant is not hampered or impeded by a lack of access to the Judiciary. Again, there is an over provision of this service, to ensure that there are no delays in the out of hours operations.” Source location Response from HMCTS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a central team and access routes through London magistrates’ courts for urgent warrant applications.
Verbatim wording from the response “Had the application been considered and assessed as urgent, emergency procedures are well established for applications to be made within the working week – and out of hours on a 24/7 basis.” Source location Response from HMCTS
Open published response
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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 practitioners with guidance describing booking arrangements for non-urgent, urgent and out-of-hours applications.
Verbatim wording from the response “3) As above, the application was considered 3 working days after submission. Had the case been considered urgent, established procedures existed. Guidance to practitioners describing the scheme for booking non-urgent, urgent and out of hours applications had been provided by HMCTS. Regular inter-agency meetings provide for discussion about service provision. No concerns about service provision have ever been raised with HMCTS by NHS colleagues. The warrant courts at Westminster and Uxbridge provide sufficient supply of hearings for non-urgent applications based on data analysis and reviews over time. All London magistrates’ courts are available at any time for urgent applications. A central team provides access to urgent applications on request. This service is used relatively frequently by AMHPs.” Source location Response from HMCTS
Open published response
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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 applying to court for a section 135(1) warrant rests with Approved Mental Health Professionals, who are the only authorised applicants.
Verbatim wording from the response “Applying for a warrant under Section 135(1) of the Mental Health Act (MHA) 1983” Source location Response from MPS
Open published response
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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 application was non-urgent, was granted within three working days, and involved no delay attributable to court listing.
Verbatim wording from the response “Evidence presented to the Inquest confirmed that the application was made on 18 August with an intended date for execution on 7 September 2023.” Source location Response from HMCTS
Open published response
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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 booking, open-door, urgent and out-of-hours arrangements provide sufficient access to magistrates’ courts for mental health warrant applications.
Verbatim wording from the response “2) Whilst there is a maximum number of hearing slots within the online booking system, the applicant’s access to a court hearing is not limited to the online booking slots. It is long established practice and procedure for mental health practitioners to attend court and apply for urgent mental health warrants.” Source location Response from HMCTS
Open published response
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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 Arrangements for executing warrants, including any fast-track procedure, do not fall within magistrates’ courts’ responsibilities.
Verbatim wording from the response “4) This matter does not apply to the magistrates’ courts responsibilities.” Source location Response from HMCTS
Open published response
26 Sep 2024 Charne Nikita Petit · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Detention of patients in general hospitals without a section while awaiting a mental health bed View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Charne Nikita Petit · 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
Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.
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 Detention of patients in general hospitals without a section while awaiting a mental health bed
Wider context from the report “(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed , because they cannot be placed under section unless a mental health bed is available.
” Source location Charne Nikita Petit · Prevention of Future Deaths report
Open source report
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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 Invest in new mental health units and community, crisis, and acute services to improve access and reduce avoidable admissions.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.” Source location Response from NHSE
Open published response
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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 Direct systems to reduce average adult acute mental health ward stays and improve timely access to local beds.
Verbatim wording from the response “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.” Source location Response from NHSE
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide recurrent funding to integrated care boards to recommission inpatient care in line with evidence-based therapeutic local models.
Verbatim wording from the response “This is being supplemented by a further £42m recurrent investment from 2024/25 for all ICBs in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Detention under the Mental Health Act in an acute hospital can occur only with the acute Trust’s agreement.
Verbatim wording from the response “Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited.” Source location Response from Surrey and Borders Partnership
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5 Feb 2024 Abdullah Popalzai · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Unavailability of suitable psychiatric hospital bed spaces in a timely way View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
View source
NHS England
Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
View source
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AI-generated summary
Abdullah Popalzai · 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
Abdullah Popalzai was a remand prisoner at HMP Pentonville who was found hanging in his cell on 29 November 2019, and his death was confirmed by paramedics. He had acute psychosis and required transfer to a psychiatric unit, but no suitable bed was available for a prolonged period. The principal concern was that acutely psychotic prisoners refusing treatment were being left untreated and at risk of deterioration because suitable psychiatric hospital beds were not becoming available in a timely way.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of suitable psychiatric hospital bed spaces in a timely way
Wider context from the report “1) Prisoners who are acutely psychotic and refusing treatment that requires transfer to hospital under the Mental Health Act are being left untreated and at risk of further deterioration due to a shortage of suitable psychiatric hospital bed spaces becoming available in a timely way .
” Source location Abdullah Popalzai · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
Verbatim wording from the response “NHS England is committed to ensuring access to timely, responsive, and least restrictive mental health care and is already working to address this in this area by focusing on increasing access to hospital beds pre-sentence, rather than prison being used as a place of safety.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Verbatim wording from the response “His Majesty’s Inspectorate of Prisons (HMIP) recently published the report The long wait: A thematic review of delays in the transfer of mentally unwell prisoners which outlines similar issues. NHS England is also addressing the areas of concern and lessons learnt within this report.” Source location Response from NHS England
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27 Apr 2023 Ben Alan SHIPLEY · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Delays in completing Mental Health Act detention when no bed is available overnight View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ben Alan SHIPLEY · 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
Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in completing Mental Health Act detention when no bed is available overnight
Wider context from the report “Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed . Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night . This means Ben cannot be legally detained as the section 2 is not complete until there is a bed . He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████
████████
” Source location Ben Alan SHIPLEY · Prevention of Future Deaths report
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19 Dec 2022 Mollie Rose Stansfield · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Mollie Rose Stansfield · 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
Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect . Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” Source location Mollie Rose Stansfield · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the Mental Health Order’s patient-detention powers with HSC Trust chief executives and relevant professional bodies.
Verbatim wording from the response “Having considered the findings of the report, I agree with the importance of ensuring that Health and Social Care Trusts and relevant health practitioners here should be reminded of the powers under the Mental Health Order for the detention of patients. I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.” Source location Response from Department of Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a pilot enabling SAS doctors to gain Section 5(2) competence through the portfolio route.
Verbatim wording from the response “In order to enable additional further capacity, HEE is also currently undertaking a pilot to allow Specialty and Associate Specialist (SAS) doctors to gain competence via the same portfolio route as non-medical staff. SAS doctors are employed in the NHS in a non-training post and will have at least seven years’ experience of working in psychiatry, four of which at a senior level.” Source location Response from NHS England
Open published response
Concerns raised 1
Delays in accepting transfers of patients under a section View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ann Pickering · 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
Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in accepting transfers of patients under a section
Wider context from the report “During the inquest, evidence showed:-
1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required.
2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer
3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21
4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them.
” Source location Ann Pickering · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.
Verbatim wording from the response “An interim guidance protocol to both BHNFT and SWYPFT staff will be distributed from 26 August 2022, followed by a substantive co-owned operational protocol that is to be in place by 30 September 2022 (EXHIBIT 1). In addition, an update to the existing service level agreement for the Provision of Mental Health Responsibilities – for Patients Detained under the Mental Health Act, will be amended by 30 September 2022 (EXHIBIT 1).” Source location Response from NHS South West Yorkshire Partnership
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.
Verbatim wording from the response “BHNFT and SWYPFT are improving and clarifying the process which includes a protocol that details operational delivery of a safe and effective pathway, which will include:” Source location Response from NHS South West Yorkshire Partnership
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28 Jan 2022 Jack Stephen TAYLOR · Prevention of Future Deaths report West Sussex
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Concerns raised 2
Reliance solely on police assistance to secure the return of absconding PICU patients View source Failure to consider the full range of powers to secure the return of absconding PICU patients View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Reliance solely on police assistance to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Source location Jack Stephen TAYLOR · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider the full range of powers to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Source location Jack Stephen TAYLOR · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve vehicle access and availability arrangements so staff can return patients when police involvement is unnecessary.
Verbatim wording from the response “SPFT recognises that police involvement in the return of a patient may be or may become unnecessary and, at times, a patient's return by SPFT staff, rather than the police, can be preferable to some patients. Alternatively, there will be cases where risk is such that the police must be involved in the return, hence the importance of robust risk assessments, clear communication and a dynamic joint action plan.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.
Verbatim wording from the response “In addition, an improved escalation process has been implemented and added to the AWOL Policy so that SPFT staff are clear about site-wide support available from colleagues when additional resource is required to facilitate a patient's return.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.
Verbatim wording from the response “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.” Source location 2022-0029-Response-from-Sussex-Police_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.
Verbatim wording from the response “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
14 Oct 2021 Alexandra Jane Tolley · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 2
Disclosure of absconding-response arrangements enabling circumvention of detention safeguards View source Absconding instructions incompatible with the safe-detention duty under Section 2 View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alexandra Jane Tolley · 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
Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Disclosure of absconding-response arrangements enabling circumvention of detention safeguards
Wider context from the report “6. The care plan containing the staff instruction not to restrain or follow was discussed and agreed with Ms Tolley. She was thus expressly aware that if she did decide to abscond, she knew she would be able to do so. Moreover, she was explicitly told that the staff member escorting her would return to the reception area and wait for a short period in the hope Ms Tolley would return voluntarily. The implication of this was that Ms Tolley knew she had a period of grace of around 10 minutes in which to get clear of the hospital, before the police would be asked to search for her. Whilst potentially beneficial from a therapeutic perspective, such knowledge may also inform a vulnerable patient on ways in which the protection afforded by a MHA Section could be undermined . The wisdom of explaining to a patient how the hospital staff would respond to them absconding should be reviewed.
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absconding instructions incompatible with the safe-detention duty under Section 2
Wider context from the report “2. The absconding instructions to staff (set out above) seems incompatible with the duty to detain in order to keep safe, inherent in an order under Section 2 of the Mental Health Act 1983 when viewed in the context of a patient deemed to require such intensive monitoring.
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Verbatim wording from the response “We will ensure that the learning from this case is communicated within our procedure – ensure that staff are provided with clear guidance when escorting patients of the action to be taken should leave start to break down or the patient leaves the member of staff.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review feedback on the Missing Service User Procedure to ensure it meets Trust requirements for accessibility and clarity.
Verbatim wording from the response “The Missing Service User Procedure, although led by the Trust, is jointly agreed with West Yorkshire Police. Feedback on the procedure was received from West Yorkshire Police on the 11 November 2021. Upon receipt of the regulation 28, both organisations have taken a further review of the procedure to ensure it contains the learning from the death of Ms Tolley. We are currently” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate, ratify and disseminate the revised Missing Service User Procedure, making required adjustments to associated training.
Verbatim wording from the response “The draft procedure will be circulated to stakeholders for comment on the week commencing the 13 December 2021 and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trustwide email, and any required adjustments will also be made to any associated training.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.