Recurring concern

Unclear police assistance arrangements for mental health assessments

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First reported 7 Apr 2014•Latest report 22 Oct 2019

Definition

What this concern includes

Includes failures of arrangements between police and mental-health services for requesting, defining, communicating or acting on police assistance during mental health assessments, including unclear requested tasks, mismatched expectations about the assessment and unclear information or action requirements.

Not included

  • Excludes general police attendance, emergency response or mental health assessment failures where the inter-agency police-assistance arrangement is not itself unclear.
  • Excludes generic communication, training or staffing deficiencies unless they directly impair the definition or operation of police assistance for a mental health assessment.
  • Excludes police involvement in unrelated mental health enquiries, conveyance or forced-entry processes unless the assertion concerns assistance requested to support a mental health assessment.
  • Excludes failures occurring after the police-assistance arrangement is clear where the issue is solely delayed attendance or poor clinical assessment.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2019

First to latest report issue date

Stated actions
3

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.

Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Department of Health and Social Care1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1
Suffolk Constabulary1
West Midlands 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.

  1. Birmingham and Solihull

    AI-generated summary

    Nigel Byron Abbott · 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

    On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

    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

    Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 9 · 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

    Develop electronic action cards setting out staff processes and inter-agency interactions.

    Verbatim wording from the response

    “3.5 The group is currently overseeing five main work streams in response to the Coroner’s recommendations, which are:”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · 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

    Obtain formal multi-agency approval for the revised police-assistance memorandum.

    Verbatim wording from the response

    “5.1 A new Memorandum of Understanding has been developed and agreed by all of the relevant agencies, WMP, BCC, BSMHFT and BWCH. This memorandum has been developed and will receive formal approval at the multi-agency working group on 22nd January 2020.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · 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

    Present the revised memorandum to frontline staff and deliver engagement, support and scenario testing.

    Verbatim wording from the response

    “5.3 The new memorandum provides clarity for front line staff working in pressured situations, is clear on the roles and responsibilities of the agencies involved and seeks to remove the ambiguity relating to the incorrect perception that WMP require 24 hours’ notice when providing police support. This approach has been communicated to staff in advance of the final sign off of the full document.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 3 · response
    Published 18 October 2019

    Open published response

  2. Suffolk

    AI-generated summary

    Jamie Raymond Barlow · 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

    Jamie Raymond Barlow had been receiving mental health support after concerns were raised about his wellbeing, but communication and coordination between services affected plans for a further assessment. He subsequently failed to attend a GP appointment and was found hanging near his home; concerns included better inter-agency working, clarity about police assistance, and processes for jointly managing mental health assessments where risks were perceived.

    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

    Lack of clarity about the tasks requested from police assistance

    Wider context from the report

    “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public. ”

    Source location

    Jamie Raymond Barlow · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026