Recurring concern

Unclear responsibility for Mental Health Act emergency procedures

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First reported 27 Jun 2018•Latest report 8 Sep 2019

Definition

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.

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: 3
Individual concerns: 3
Date range: 2018–2019
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Ashford and St Peter'S Hospitals NHS Foundation Trust1

East London NHS Foundation Trust1

Epsom and St Helier University Hospitals NHS Trust1

Frimley Health NHS Foundation Trust1

General Medical Council1

Hampshire and Isle of Wight Constabulary1

London Borough of Hackney1

NHS England1

NHS Hampshire and Isle of Wight Integrated Care Board1

NHS North East Hampshire and Farnham Clinical Commissioning Group1

NHS Surrey and Sussex Integrated Care Board1

Royal Surrey NHS Foundation Trust1

Surrey and Borders Partnership NHS Foundation Trust1

Surrey Police1

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.

8 Sep2019
East Sussex
Concerns raised1
1. Failure of the Mental Health Act to provide responsibility for an action plan
This report raised 5 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 2
1. Action
  Publish a White Paper setting out the Government’s full response to the Independent Review of the Mental Health Act.
  Stated by Department of Health and Social CareStated planned
2. Action
  Support the Department of Health and Social Care’s development of a response to the Independent Review of the Mental Health Act.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  The Department of Health and Social Care is responsible for responding to recommendations to amend the Mental Health Act.
  Stated by NHS EnglandRedirects responsibility
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
23 May2019
Central Hampshire
Concerns raised1
1. Failure to agree and update a common action plan for revoked s.17 leave
This report raised 5 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 2
1. Action
  Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
2. Action
  Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
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
27 Jun2018
Inner North London
Concerns raised1
1. Unclear allocation of responsibility for initiating emergency procedures under 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 1
1. Action
  Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.
  Stated by East London NHS Foundation Trust and London Borough of HackneyStated in progress
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

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

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

Concerns raised1

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

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

Actions described in response 2

Respondent positions 1

Actions described in response 2

Actions described in response 1