Recurring concern

Unreliable public-protection safeguards for s41 restriction-order patients

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First reported 16 May 2022•Latest report 16 Feb 2024

Definition

What this concern includes

Includes failures in the dedicated s41 restriction-order public-protection process, including classification of people at risk as members of the public and decisions about recalling restricted patients when significant public risk is present, whether or not mental-health deterioration has occurred.

Not included

Excludes general Mental Health Act assessment, detention or discharge failures that are not specifically connected to s41 restriction-order public-protection safeguards.
Excludes Mental Health Tribunal scrutiny and discharge-planning failures where the s41 restriction-order process is not the deficient control.
Excludes generic safeguarding, risk-assessment or family-protection deficiencies without an explicit s41 restriction-order connection.
Excludes the underlying offending, violence or public-safety outcome where no failure in an s41 safeguard is identified.

Reports: 2
Individual concerns: 3
Date range: 2022–2024
Stated actions: 4

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.

Ministry of Justice2

Cygnet Health Care Limited1

Derby City Council1

Derbyshire Constabulary1

Derbyshire Healthcare NHS Foundation Trust1

Sheffield Health Partnership University NHS Foundation Trust1

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.

16 Feb2024
Derby and Derbyshire
Concerns raised2
1. Uncontrolled overseas travel by recently discharged s.41 restricted patients
2. Failure to recall s.41 patients solely posing a significant public risk without mental-health decline
This report raised 10 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 4
1. Action
  Publish guidance for supervising conditionally discharged patients in the community.
  Stated by Ministry of JusticeStated completed
2. Action
  Share forensic casework learning, knowledge, resources, expertise, external network developments, and best-practice processes across organisations.
  Stated by Derby City CouncilStated planned
3. Action
  Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.
  Stated by Derby City CouncilStated completed
1. Action
  Consider whether changes to recall guidance are necessary.
  Stated by Ministry of JusticeStated planned
Respondent positions 2
1. Position
  Day-to-day supervision of conditionally discharged patients is the responsibility of community care teams.
  Stated by Ministry of JusticeRedirects responsibility
1. Position
  A blanket ban on overseas travel cannot be imposed because the Mental Health Act 1983 provides no mechanism for doing so.
  Stated by Ministry of JusticeUnable to act
AI-generated summary

Sobia Tabasim Khan · 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

Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

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
Uncontrolled overseas travel by recently discharged s.41 restricted patients
Wider context from the report
“e. Travel overseas for s.41 restricted patients. ████████ was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk. There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledged that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction, at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also risk. ”
Source location
Sobia Tabasim Khan · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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 recall s.41 patients solely posing a significant public risk without mental-health decline
Wider context from the report
“d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which ████████ was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that ████████ risk only existed in the context of a decline in his mental health. If an individual subject to a s.41 restriction order poses a significant risk to the public he can be protected if he can be recalled to hospital where further assessment can be undertaken. ”
Source location
Sobia Tabasim Khan · 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
Publish guidance for supervising conditionally discharged patients in the community.

Verbatim wording from the response
“In July 2023 MHCS published guidance for those supervising conditionally discharged patients in the community¹. The guidance aims to support the supervision and reporting requirements for discharged”

Source location
Response from Ministry of Justice
Page 1 · response
Published 22 February 2024
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
Share forensic casework learning, knowledge, resources, expertise, external network developments, and best-practice processes across organisations.

Verbatim wording from the response
“In addition to this, the role will work on key aspects of service and practice development by:”

Source location
Response from Derby City Council
Page 2 · response
Published 22 February 2024
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
Provide regular jointly funded Social Supervisor training, including introductory Part 3 Mental Health Act training and annual refresher training.

Verbatim wording from the response
“The Council has also introduced training for social supervisors funded jointly by health and social care; previously this was provided on an "ad hoc" basis and was agency specific. Broadly covering all of the matters of concern, in September 2019 Derby City Council in conjunction with Derbyshire County Council commissioned regular training for social supervisors. There is a two day introduction to Part 3 Mental Health Act 1983 and the role of the Social Supervisor and a one day annual refresher.”

Source location
Response from Derby City Council
Page 2 · response
Published 22 February 2024
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
Consider whether changes to recall guidance are necessary.

Verbatim wording from the response
“When considering recall, MHCS guidance³ is clear that ‘(T)here is no need for the patient’s mental health to have necessarily deteriorated in order to justify recall’. MHCS can and do recall restricted patients where there is an increased risk to others in order to protect the public. My officials regularly update guidance for those working with restricted patients including the publication of guidance on s42 discharge in March 2022 and shall consider whether any changes to the recall guidance are necessary.”

Source location
Response from Ministry of Justice
Page 2 · response
Published 22 February 2024
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
Day-to-day supervision of conditionally discharged patients is the responsibility of community care teams.

Verbatim wording from the response
“The Mental Health Casework Section (MHCS) in HMPPS exercises the Secretary of State’s statutory powers under the Mental Health Act 1983 (MHA 1983), whilst the day to day supervision of conditionally discharged patients is the responsibility of the care team in the community.”

Source location
Response from Ministry of Justice
Page 1 · response
Published 22 February 2024
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
A blanket ban on overseas travel cannot be imposed because the Mental Health Act 1983 provides no mechanism for doing so.

Verbatim wording from the response
“One of your concerns centred on the fact that ████████ was allowed to travel to Pakistan soon after his discharge into the community. Under the MHA 1983, there is no statutory bar to overseas travel for conditionally discharged patients and no mechanism for the Secretary of State to impose a blanket ban on all overseas travel. However, guidance published in July 2023 underlines the following expectations:”

Source location
Response from Ministry of Justice
Page 2 · response
Published 22 February 2024
Open published response
16 May2022
South Yorkshire (Western)
Concerns raised1
1. Failure to regard identified family members at risk of harm as members of the public for s41 Order purposes
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 3
1. Position
  The sentencing judge is responsible for deciding whether to impose a Section 41 Restriction Order with a Section 37 Hospital Order.
  Stated by Probation ServiceRedirects responsibility
1. Position
  Clinical risk assessments and interpretations by independent psychiatrists are outside the Ministry of Justice’s remit for comment.
  Stated by Probation ServiceOutside remit
2. Position
  Challenges to independent judicial decision-making are outside the Probation Service’s remit for comment.
  Stated by Probation ServiceOutside remit
AI-generated summary

Marjorie Grayson · 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

Marjorie Grayson died by suicide on 3 September 2020 after falling from a first-floor bedroom window at her home. The report identified concerns about the use of a hospital order without additional restrictions, inadequate consideration of the seriousness of her previous offence and impulse-control risks, limited face-to-face contact after discharge during the Covid-19 pandemic, and insufficient support and communication for her family.

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 regard identified family members at risk of harm as members of the public for s41 Order purposes
Wider context from the report
“4. I am unclear why members of Mrs Grayson's family, who do not reside with her ordinarily and at the time of her offending, are not regarded as members of the public for the purposes of a s41 Order. The risk of harm to them was clear in the mind of the author and had they been regarded as members of the public this may have led to a s41 Order being made which, although potentially making no difference in this case, may do so in others. ”
Source location
Marjorie Grayson · Prevention of Future Deaths report
Page 5 · concerns
Open source report
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 sentencing judge is responsible for deciding whether to impose a Section 41 Restriction Order with a Section 37 Hospital Order.

Verbatim wording from the response
“It is a matter for the sentencing Judge, as a member of the independent judiciary, to determine whether a Section 41 Restriction Order should be imposed with a Section 37 Hospital Order. In Mrs Grayson’s case, the sentencing Judge, in the exercise of his discretion, considered independent expert psychiatric evidence to determine if a Section 41 Restriction Order was appropriate, in order to pass sentence.”

Source location
Response from Government Legal Department
Page 1 · response
Published 19 May 2022
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
Clinical risk assessments and interpretations by independent psychiatrists are outside the Ministry of Justice’s remit for comment.

Verbatim wording from the response
“The reports provided to the Court by two registered independent expert psychiatrists were on the instruction of Mrs Grayson’s defence solicitors for the purposes of the sentencing hearing. The reports are independent and not on the instruction of the Ministry of Justice. Therefore, concerns relating to the clinical judgement and assessment of Mrs Grayson, in respect of the assessment of risk and interpretation of ‘members of the public’ is not something the Ministry of Justice can comment on.”

Source location
Response from Government Legal Department
Page 1 · response
Published 19 May 2022
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
Challenges to independent judicial decision-making are outside the Probation Service’s remit for comment.

Verbatim wording from the response
“It would also not be appropriate for the Probation Service to comment on any challenge to independent judicial decision making. The Probation Service do not know what was relied upon by the Judge in his discretion when passing sentence and what parts of the independent expert evidence were accepted, or which expert gave oral evidence. To assist you in addressing your concerns we have instructions to obtain the Court transcript for Mrs Grayson’s sentencing hearing, including the sentencing remarks. We understand that this will provide more information as to the rationale of the Judge’s decision making.”

Source location
Response from Government Legal Department
Page 1 · response
Published 19 May 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Uncontrolled overseas travel by recently discharged s.41 restricted patients

Failure to recall s.41 patients solely posing a significant public risk without mental-health decline

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.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to regard identified family members at risk of harm as members of the public for s41 Order purposes

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 4

Respondent positions 2

Respondent positions 3