Recurring concern

Unreliable alignment between police guidance and legal powers for safety-critical interventions

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First reported 28 Dec 2018•Latest report 24 Apr 2026

Definition

What this concern includes

Includes failures in police or inter-agency arrangements where guidance, statutory powers and operational practice for a safety-critical intervention are inconsistent, unclear or not jointly understood, including the anchor's domestic-violence and former-cohabitant context and Section 136 cases originating from a home address.

Not included

  • Excludes ordinary policy or legal ambiguity without a direct safety-critical intervention or protective-action consequence.
  • Excludes failures in the substantive exercise of a clearly understood police power when the guidance and legal position are aligned.
  • Excludes generic police training, communication or role-clarity deficiencies that are not specifically caused by a mismatch between guidance, legal powers and operational practice.
  • Excludes unrelated statutory powers, detention processes or domestic-abuse arrangements where no police-guidance and legal-powers alignment issue is identified.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2018–2026

First to latest report issue date

Stated actions
13

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 England2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
College of Policing1
Department of Health and Social Care1
Greater Manchester Police1
Home Office1
London Ambulance Service NHS Trust1
Metropolitan Police Service1
NHS Birmingham and Solihull Integrated Care Board1
NHS Greater Manchester Integrated Care Board1
North West Ambulance Service NHS Trust1
OneLondon Board1
Pennine Care NHS Foundation Trust1
South London and Maudsley 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.

  1. Inner West London

    AI-generated summary

    Edward Muwanga · 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

    Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

    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 understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation

    Wider context from the report

    “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation ”

    Source location

    Edward Muwanga · Prevention of Future Deaths report
    Page 5 · concerns

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    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

    Review Authorised Professional Practice guidance and consider the report’s concerns in resulting amendments.

    Verbatim wording from the response

    “The College of Policing recognises the risks associated with mental health incidents and we understand the critical importance of decisions about the appropriate response to such calls. The police response to mental health incidents is covered within the guidance produced by the College under the Authorised Professional Practice (APP). The APP is currently going through a formal review and we will ensure that the points highlighted within your report are fully considered within any amendments made within the review process.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 19 June 2026

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    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

    Deliver comprehensive training on Mental Health Act sections 135 and 136, including communal-area powers, warrants, and safeguarding.

    Verbatim wording from the response

    “The MPS acknowledges the findings of the inquest and the concerns raised in this report, and we have taken substantive steps to strengthen training, policy, and operational practice.”

    Source location

    Response from Metropolitan Police
    Page 1 · response
    Published 19 June 2026

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    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

    Issue operational notices clarifying the lawful use of section 136 powers in communal areas.

    Verbatim wording from the response

    “All officers now receive structured and comprehensive training on sections 135 and 136 of the Mental Health Act. This includes specific instruction on the lawful use of section 136 powers in communal areas, with explicit clarification reinforced through operational notices issued to all frontline staff. Officers are also trained on the purpose and execution of section 135 warrants, including the respective roles of health professionals and the importance of safeguarding considerations. Training is delivered through a blended approach, combining classroom learning, scenario-based exercises, and ongoing professional development to ensure both legal understanding and effective practical application.”

    Source location

    Response from Metropolitan Police
    Page 1 · response
    Published 19 June 2026

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    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

    Embed enhanced supervisory oversight and escalation processes within control-room decision-making.

    Verbatim wording from the response

    “Since the inquest, the MPS has taken further steps to strengthen these arrangements. Guidance on the application of section 136 in communal settings has been reinforced to remove any ambiguity, and updated policy and operational processes have improved consistency in identifying and executing section 135 warrants. Enhanced supervisory oversight and escalation processes are now embedded within control room decision-making. Taken together, these measures directly address the issues identified in the report and provide assurance that officers are better equipped to make lawful, informed, and proportionate decisions.”

    Source location

    Response from Metropolitan Police
    Page 2 · response
    Published 19 June 2026

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    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

    Continue reinforcing Mental Health Act and Right Care, Right Person training through regular audit and quality assurance.

    Verbatim wording from the response

    “Alongside this, the MPS will continue to reinforce training on Mental Health Act powers and the Right Care, Right Person framework, supported by regular audit and quality assurance to ensure consistent and effective decision-making.”

    Source location

    Response from Metropolitan Police
    Page 3 · response
    Published 19 June 2026

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    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 Metropolitan Police Service is responsible for addressing operational elements and decision-making processes and is providing the substantive response.

    Verbatim wording from the response

    “In relation to the operational elements and decision-making processes, we have been in contact with the Metropolitan Police Service (MPS) and understand that a full response to these points is being provided.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 19 June 2026

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Sharon Elaine Harman · 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

    Elaine Harman was assaulted by her husband, who breached police bail conditions by attending their home and stabbing her to death on 6 August 2021. The principal concern was an apparent disconnect between policing guidance and available legal powers, including the absence of a power to retain a house key during bail conditions in domestic violence cases.

    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

    Disconnect between police guidance and available legal powers in domestic violence cases involving former cohabitants

    Wider context from the report

    “There appears an obvious disconnect in the guidance issued by the College of Policing and the laws provided to police under s19 PACE or otherwise. This appears of particular concern in cases of domestic violence where, previously, the parties have lived together. ”

    Source location

    Sharon Elaine Harman · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Consult stakeholders and review legislation and Codes of Practice to assess whether police powers remain proportionate, necessary and appropriately safeguarded.

    Verbatim wording from the response

    “Thank you for bringing to our attention the disconnect between the College of Policing guidance and the powers provided to the police under s19 PACE. We will look to raise these discrepancies with the College of Policing. In terms of the recommendation to consider an additional power for police to retain house keys (for the duration of bail conditions only), we regularly consult with stakeholders, review existing legislation and associated Codes of Practice including any requirements for legislative reform, to ensure that the powers available to the police and law enforcement bodies are reasonable, proportionate and necessary in the circumstances, with the requisite safeguards to protect the rights of individuals and victims.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 28 February 2023

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  3. 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 between agencies about urgent section 135 warrant requirements

    Wider context from the report

    “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how. The context for this report is: (1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice. (2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident. (3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed. (4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected. My on-going concern is that the agencies involved in this area are not working together effectively. 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. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 2 · concerns

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    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

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    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

    Operate multi-agency call-in and prioritisation for Section 135 requests.

    Verbatim wording from the response

    “3.6 Clarity has been introduced in relation to the use of sections 135 and 136 of the Mental Health Act. Section 135 requests are now subject to multi agency ‘call in’ and prioritisation at 10am and 7pm. This process has only recently been introduced, and it is recognised that a more robust escalation process is needed to determine priority cases.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 18 October 2019

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    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

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    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

  4. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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

    Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face 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

    Lack of clarity about police powers and role for Section 136 from-home cases

    Wider context from the report

    “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst other agencies. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Review, revise and enhance multi-agency procedures through sessions involving all named partner organisations.

    Verbatim wording from the response

    “Several distinct sessions were convened to review, revise and enhance our existing procedures from multiple perspectives. These sessions each included insight and oversight from all partner organisations named in this letter.”

    Source location

    2018-0411-Response-by-GMCA
    Page 2 · response
    Published 28 December 2018

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    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 a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.

    Verbatim wording from the response

    “We have now drawn together a pan-GM protocol for response, developed specifically in order to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk; and to promote communication and escalation at the first point that a common understanding may falter.”

    Source location

    2018-0411-Response-by-GMCA
    Page 3 · response
    Published 28 December 2018

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    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 better disseminating police powers, obligations and limitations to partner agencies through joint working initiatives.

    Verbatim wording from the response

    “It is accepted that there may be a requirement to improve the understanding amongst partner agencies about police powers in responding to concerns for welfare where the person in question is in a private dwelling. However, the police officers who gave evidence as part of the inquest proceedings demonstrated that they had an accurate understanding of their powers – and the limitations thereon – under s.136. Where a concern for welfare is received in relation to an individual who is within a private dwelling, there is an option under s.135 of the same Act to require the attendance of qualified mental health practitioners to undertake a formal mental health assessment, following which it will be possible for officers to convey an individual found to require detention under the Act to a health-based place of safety.”

    Source location

    2018-0411-Response-by-Greater-Manchester-Police
    Page 2 · response
    Published 28 December 2018

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    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

    Detention under section 136 was lawful because the person was found in the street, not a private dwelling.

    Verbatim wording from the response

    “Response: Had Mr Rekwowski been taken to hospital under s.136 of the Mental Health Act 1983 (MHA) from his home address on 17 September 2017, this would have been unlawful as the exercise of powers under s.136 requires that the person who is the subject of detention is not in their own home (s.136(1A)). When police attended on 17 September, Mr Rekwowski was, in actual fact, found to be in the street and was lawfully detained pursuant to the police’s s.136 powers as he was not in a private dwelling. This is confirmed within police documentation disclosed in the Inquest proceedings:”

    Source location

    2018-0411-Response-by-Greater-Manchester-Police
    Page 1 · response
    Published 28 December 2018

    Open published response
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Data last updated 7 September 2026