First reported 12 Nov 2015•Latest report 28 Oct 2025
Definition
What this concern includes
Includes failures in explicitly Mental Health Act detention arrangements, including safe-detention instructions, lawful application of detention powers, transfer to appropriate secure mental-health facilities and coordination needed to maintain safe detention and treatment under the Act.
Not included
Excludes Section 136-specific procedures where the assertion is confined to Section 136; that named process has a separate existing concern.
Excludes failures in clinical treatment, discharge or follow-up after Mental Health Act detention arrangements have operated reliably.
Excludes generic mental-health service capacity, communication or staffing deficiencies unless they directly impair Mental Health Act detention, transfer or safe protective arrangements.
Excludes unrelated Mental Capacity Act, Deprivation of Liberty Safeguards and ordinary informal-patient processes unless the assertion also concerns Mental Health Act detention arrangements.
Reports
17
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
45
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England6
Department of Health and Social Care3
Surrey and Borders Partnership NHS Foundation Trust2
All Interested Persons1
Avon and Somerset Constabulary1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Barnsley Hospital1
Birmingham City Council1
Birmingham Women'S and Children'S NHS Foundation Trust1
Cornwall Partnership NHS Foundation Trust1
Cygnet Health Care Limited1
Devon & Cornwall Police1
Devon Partnership NHS Trust1
Elysium Healthcare Limited1
Epsom Hospital1
NHS trust10
Executive non-departmental public body7
Ministerial department4
Police force3
English metropolitan district council2
Healthcare site2
Community interest company1
Coronial office1
Executive agency1
Health and care professional regulator1
Health-system partnership1
Independent healthcare provider1
Integrated care board1
Private limited company1
Professional body1
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.
Exeter and Greater Devon
Concerns raised1
Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Continue liaising with South West Provider Collaborative partners to help develop the regional Memorandum of Understanding.
Stated by Avon and Somerset ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 9 April 2020.
Action
Work with other force areas and the South West Provider Collaborative to develop a Memorandum of Understanding.
Stated by Wiltshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 9 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mental health service pathways are outside the Police Service’s remit.
Stated by Wiltshire PoliceOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Police rely on the NHS to provide diversion from limited criminal justice options.
Stated by Wiltshire PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to place patients on the recommended Mental Health Act section
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Delays in arranging assessment, detention choice and Walsall Council’s investigation were matters for the other identified bodies to address.
Stated by Priory GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2019.
Action
Submit revised prisoner transfer and remission guidance for public consultation.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
Action
Implement the revised prisoner transfer and remission guidance nationally after consultation.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
Action
Conduct annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
Action
Develop improved performance management through increased collection and analysis of transfer pathway data.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
Action
Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
Action
Conduct demand and capacity reviews for adult high-, medium- and low-secure mental health services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
Action
Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
Action
Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The report does not establish the extent to which delayed transfer contributed to the death.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Southampton and New Forest
Concerns raised1
Failure of ward nurses to use section 5(4) powers to prevent unsafe patient departure
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London Greater (East)
Concerns raised1
Lack of staff awareness of nurses' holding power under Section 5.4 of the Mental Health Act
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Explore whether a registered mental health nurse can be provided at short notice when high-risk patients cannot be assessed within the specified time.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 August 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The hospital cannot exercise Mental Health Act holding powers because it does not provide mental health services or employ authorised registered mental health nurses.
Stated by Royal Free London NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Mental health services and registered mental health nurse support are provided by Barnet, Enfield & Haringey Mental Health Trust.
Stated by Royal Free London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to distinguish urgent DOLS applications from detention under Section 3 of the Mental Health Act
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Deliver bespoke Deprivation of Liberty Safeguards training to senior clinical staff, including its relationship with the Mental Health Act and place-specific requirements.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 April 2016.
Action
Require all staff to complete a mandatory Deprivation of Liberty Safeguards training package and monitor completion through the ward manager.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Review end-of-life care and consider the most appropriate legal framework for depriving a patient of liberty.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 April 2016.
Inner North London
Concerns raised1
Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015.
Action
Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures in explicitly Mental Health Act detention arrangements, including safe-detention instructions, lawful application of detention powers, transfer to appropriate secure mental-health facilities and coordination needed to maintain safe detention and treatment under the Act.
