Unreliable Mental Health Act detention arrangements
First to latest report 12 Nov 2015 — 28 Oct 2025
Reports that mention this concern
17
Times this concern has been raised
20
Stated actions linked to this concern
45
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 17 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked responses
Avon and Somerset Constabulary
Wiltshire Police
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
Avon and Somerset Constabulary
Continue liaising with South West Provider Collaborative partners to help develop the regional Memorandum of Understanding.
Wiltshire Police
Work with other force areas and the South West Provider Collaborative to develop a Memorandum of Understanding.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Wiltshire Police
Mental health service pathways are outside the Police Service’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Wiltshire Police
The Police rely on the NHS to provide diversion from limited criminal justice options.
Redirects 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.
Linked response
Priory Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Priory Group
Delays in arranging assessment, detention choice and Walsall Council’s investigation were matters for the other identified bodies to address.
Redirects 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
Linked responses
Department of Health and Social Care
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
NHS England
Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.
NHS England
Submit revised prisoner transfer and remission guidance for public consultation.
NHS England
Implement the revised prisoner transfer and remission guidance nationally after consultation.
NHS England
Conduct annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.
NHS England
Develop improved performance management through increased collection and analysis of transfer pathway data.
NHS England
Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.
NHS England
Conduct demand and capacity reviews for adult high-, medium- and low-secure mental health services.
NHS England
Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.
NHS England
Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Department of Health and Social Care
The report does not establish the extent to which delayed transfer contributed to the death.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Department of Health and Social Care
NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
The Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
NHS England
Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.
Redirects 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.
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.
Linked response
Royal Free London 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.1
Royal Free London NHS Foundation Trust
Explore whether a registered mental health nurse can be provided at short notice when high-risk patients cannot be assessed within the specified time.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Royal Free London NHS Foundation Trust
The hospital cannot exercise Mental Health Act holding powers because it does not provide mental health services or employ authorised registered mental health nurses.
Outside remitThe respondent said that this matter was outside its role or authority.
Royal Free London NHS Foundation Trust
Mental health services and registered mental health nurse support are provided by Barnet, Enfield & Haringey Mental Health Trust.
Redirects 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.
Linked response
Greater Manchester Mental Health 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.3
Greater Manchester Mental Health NHS Foundation Trust
Deliver bespoke Deprivation of Liberty Safeguards training to senior clinical staff, including its relationship with the Mental Health Act and place-specific requirements.
Greater Manchester Mental Health NHS Foundation Trust
Require all staff to complete a mandatory Deprivation of Liberty Safeguards training package and monitor completion through the ward manager.
Greater Manchester Mental Health NHS Foundation Trust
Review end-of-life care and consider the most appropriate legal framework for depriving a patient of liberty.
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.
Linked responses
North London NHS Foundation Trust
Whittington Health NHS 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.2
North London NHS Foundation Trust and Whittington Health NHS Trust
Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
North London NHS Foundation Trust and Whittington Health NHS Trust
Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
North London NHS Foundation Trust and Whittington Health NHS Trust
Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
North London NHS Foundation Trust and Whittington Health NHS Trust
The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
North London NHS Foundation Trust and Whittington Health NHS Trust
The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.