Recurring concern

Unclear responsibility for Mental Health Act emergency procedures

First to latest report 27 Jun 2018 — 8 Sep 2019

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
5

What this concern includes

Includes failures in the Mental Health Act system concerning responsibility for emergency action, including legislative recognition of responsibility, assignment between relevant functions, action-plan ownership and operational understanding of who must initiate emergency procedures.

What is not included
  • Excludes failures in Mental Health Act assessment, detention or treatment where responsibility for emergency action is not the identified concern.
  • Excludes Section 136-specific operational failures unless the assertion directly concerns the wider Mental Health Act emergency-procedure responsibility arrangement.
  • Excludes generic accountability, care-coordination or emergency-response failures without an explicit Mental Health Act connection.
  • Excludes failures in executing an emergency action after responsibility was clearly assigned and understood.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East Sussex

    AI-generated summary

    Reece Tristan Lapina-Amarelle · 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

    Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the Mental Health Act to provide responsibility for an action plan

    Wider context from the report

    “(4) In my opinion the Mental Health Act is out of date in that it does not recognise or accept responsibility for providing a plan of action to deal with people such as Reece. ”

    Source location

    Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish a White Paper setting out the Government’s full response to the Independent Review of the Mental Health Act.

    Verbatim wording from the response

    “More generally, as you are aware, we commissioned a full and independent review of the Mental Health Act. The Independent Review of the Mental Health Act was published on 6 December 2018⁷. The Review made 154 recommendations. If implemented they would give more legal weight to people’s choices, make the use of compulsion more targeted and transparent, and modernise services to provide patient-centred care which respects the patient’s dignity.”

    Source location

    2019-0274-Response-by-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 18 October 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Support the Department of Health and Social Care’s development of a response to the Independent Review of the Mental Health Act.

    Verbatim wording from the response

    “As the government department responsible for this legislation, the Department of Health and Social Care is currently developing a response to the Independent Review’s recommendations, and NHS England and NHS Improvement are involved in, and supporting this process. The Government has committed to publishing a White Paper before the end of the year.”

    Source location

    2019-0274-Response-by-NHS-England
    Page 4 · response
    Published 18 October 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Department of Health and Social Care is responsible for responding to recommendations to amend the Mental Health Act.

    Verbatim wording from the response

    “As the government department responsible for this legislation, the Department of Health and Social Care is currently developing a response to the Independent Review’s recommendations, and NHS England and NHS Improvement are involved in, and supporting this process. The Government has committed to publishing a White Paper before the end of the year.”

    Source location

    2019-0274-Response-by-NHS-England
    Page 4 · response
    Published 18 October 2019

    Open published response

  2. Central Hampshire

    AI-generated summary

    Sasha Sabrina FORSTER · 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

    Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to agree and update a common action plan for revoked s.17 leave

    Wider context from the report

    “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances. As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not. ”

    Source location

    Sasha Sabrina FORSTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.

    Verbatim wording from the response

    “The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”

    Source location

    Sasha-Forster-R2019-01692
    Page 2 · response
    Published 2 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.

    Verbatim wording from the response

    “To respond to the PFD, a meeting was held on the 01 July 2019 between a number of the key stakeholders named in the PFD. Below is a summary of the discussions and actions that were agreed moving forwards. A further meeting will be held to discuss and evidence dissemination of learning and training.”

    Source location

    Sasha-Forster-R2019-01692
    Page 2 · response
    Published 2 August 2019

    Open published response

  3. Inner North London

    AI-generated summary

    Dudley Vincent Brown · 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

    Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.

    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

    Unclear allocation of responsibility for initiating emergency procedures under the Mental Health Act

    Wider context from the report

    “(1) Following the incident on 29 December 2017, the incident was reported to police the same day. The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act. ”

    Source location

    Dudley Vincent Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.

    Verbatim wording from the response

    “This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.”

    Source location

    2018-0211-Response-by-Hackney-Borough-Council
    Page 1 · response
    Published 14 August 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026