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.
West Sussex, Brighton and Hove
Concerns raised1
Lack of a safe lawful detention pathway for people who cannot be held under s.3 at the hospital
This report raised 6 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
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 October 2025.
Surrey
Concerns raised1
Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
This report raised 12 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.5
Action
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Engage stakeholders to clarify how the current legal framework applies to holding patients in A&E and identify solutions to the reported problems.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Provide further guidance on the legal framework and handover protocol in the next revision of the Mental Health Act Code of Practice.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Engage further to understand application of the current legal framework and identify solutions to unlawful detention risks in A&E.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Provide further guidance on the legal framework and health-police handover protocol in the next revision of the Mental Health Act Code of Practice.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The acute hospital’s management is responsible for deciding whether to detain a patient to an acute hospital bed.
Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Stated by Epsom and St Helier University Hospitals NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinical matters fall outside the commissioning organisation’s remit.
Stated by NHS Southwest London Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Clinical matters are the responsibility of the relevant Trusts.
Stated by NHS Southwest London Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised2
Delays in obtaining Magistrates Court hearings for s135(1) warrant applications
Lack of an official fast-track procedure for s135(1) warrants
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.8
Action
Review the corporate section 135 warrant process and incorporate matters raised in the report and identified learning.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2025.
Action
Prioritise mental health warrant applications as priority-one work when allocating court time.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide remote mental health warrant applications with online self-service booking.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide two separate remote warrant sessions daily on weekdays, with capacity exceeding typical demand.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Maintain an open-door process allowing applicants to obtain immediate access to a courtroom for warrant applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide out-of-hours access to the Judiciary for urgent mental health warrant applications seven days a week.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide a central team and access routes through London magistrates’ courts for urgent warrant applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide practitioners with guidance describing booking arrangements for non-urgent, urgent and out-of-hours applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Responsibility for applying to court for a section 135(1) warrant rests with Approved Mental Health Professionals, who are the only authorised applicants.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The application was non-urgent, was granted within three working days, and involved no delay attributable to court listing.
Stated by HM Courts & Tribunals ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing booking, open-door, urgent and out-of-hours arrangements provide sufficient access to magistrates’ courts for mental health warrant applications.
Stated by HM Courts & Tribunals ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Arrangements for executing warrants, including any fast-track procedure, do not fall within magistrates’ courts’ responsibilities.
Stated by HM Courts & Tribunals ServiceOutside remitThe respondent said that this matter was outside its role or authority.
Surrey
Concerns raised1
Detention of patients in general hospitals without a section while awaiting a mental health bed
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.3
Action
Invest in new mental health units and community, crisis, and acute services to improve access and reduce avoidable admissions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2024.
Action
Direct systems to reduce average adult acute mental health ward stays and improve timely access to local beds.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2024.
Action
Provide recurrent funding to integrated care boards to recommission inpatient care in line with evidence-based therapeutic local models.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Detention under the Mental Health Act in an acute hospital can occur only with the acute Trust’s agreement.
Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Unavailability of suitable psychiatric hospital bed spaces in a timely way
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
Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
West Yorkshire (Western)
Concerns raised1
Delays in completing Mental Health Act detention when no bed is available overnight
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East Riding and Hull
Concerns raised1
Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power
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
Raise the Mental Health Order’s patient-detention powers with HSC Trust chief executives and relevant professional bodies.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2023.
Action
Run a pilot enabling SAS doctors to gain Section 5(2) competence through the portfolio route.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2023.
South Yorkshire (Western)
Concerns raised1
Delays in accepting transfers of patients under a section
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
Action
Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
West Sussex
Concerns raised2
Reliance solely on police assistance to secure the return of absconding PICU patients
Failure to consider the full range of powers to secure the return of absconding PICU patients
This report raised 7 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
Improve vehicle access and availability arrangements so staff can return patients when police involvement is unnecessary.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Implement an escalation process clarifying site-wide colleague support when additional resources are needed for patient return.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.
Stated by Sussex PoliceOutside remitThe respondent said that this matter was outside its role or authority.
Position
Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.
Stated by Sussex PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised2
Disclosure of absconding-response arrangements enabling circumvention of detention safeguards
Absconding instructions incompatible with the safe-detention duty under Section 2
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Action
Review feedback on the Missing Service User Procedure to ensure it meets Trust requirements for accessibility and clarity.
Stated by Leeds and York Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Circulate, ratify and disseminate the revised Missing Service User Procedure, making required adjustments to associated training.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
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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.
