Recurring concern

Unreliable Section 135 mental health warrant procedures

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First reported 6 Nov 2017•Latest report 24 Apr 2026

Definition

What this concern includes

Includes failures in the dedicated Section 135 warrant process, including officer understanding of the statutory procedure, access to warrant information, pre-entry briefing and risk assessment, warrant verification, role allocation, entry arrangements and related safeguards for people in mental health crisis.

Not included

  • Excludes Section 136, Section 5, Section 17 leave and other Mental Health Act processes unless the assertion explicitly concerns a Section 135 warrant.
  • Excludes generic police training, briefing or risk-assessment deficiencies where Section 135 warrant operation is not the identified safety concern.
  • Excludes clinical mental-health assessment, treatment or detention decisions after the warrant-entry process has operated adequately.
  • Excludes general police entry, search or premises-access failures without a Section 135 mental health warrant context.
Reports
5

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2017–2026

First to latest report issue date

Stated actions
28

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.

Metropolitan Police Service3
NHS England3
Department of Health and Social Care2
Ministry of Justice2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
College of Policing1
Home Office1
London Ambulance Service NHS Trust1
NHS Birmingham and Solihull Integrated Care Board1
Nottinghamshire County Council1
Nottinghamshire Healthcare NHS Foundation Trust1
Nottinghamshire Police1
OneLondon Board1
Police and Crime Commissioner for Nottinghamshire1

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

    Lack of awareness of the section 135 MHA 1980 process

    Wider context from the report

    “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers. ”

    Source location

    Edward Muwanga · Prevention of Future Deaths report
    Page 5 · 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 locate and identify information about a section 135 MHA 1980 warrant

    Wider context from the report

    “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers. ”

    Source location

    Edward Muwanga · Prevention of Future Deaths report
    Page 5 · 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

    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

    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

    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

    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

    Strengthen policy and operational processes for identifying, executing, and managing requests for assistance at section 135 warrants.

    Verbatim wording from the response

    “Separately, we acknowledge the concern regarding officers’ awareness of the existence of a section 135 warrant in this case. Recent changes to our processes ensure that section 135 warrants are recorded on police intelligence systems that are accessible to all officers. There is a clear expectation that officers will request intelligence checks when attending incidents involving vulnerable individuals, and processes have been strengthened to ensure that requests for police assistance at warrants are managed with greater clarity and consistency.”

    Source location

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

    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

    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

    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

    Record section 135 warrants on police intelligence systems accessible to all officers.

    Verbatim wording from the response

    “Separately, we acknowledge the concern regarding officers’ awareness of the existence of a section 135 warrant in this case. Recent changes to our processes ensure that section 135 warrants are recorded on police intelligence systems that are accessible to all officers. There is a clear expectation that officers will request intelligence checks when attending incidents involving vulnerable individuals, and processes have been strengthened to ensure that requests for police assistance at warrants are managed with greater clarity and consistency.”

    Source location

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

    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

    Implement the electronic Mental Health Act system to complete, process and securely share statutory documentation across organisations.

    Verbatim wording from the response

    “The eMHA by Thalamos is a digital platform used by five Mental Health Trusts in London to complete, process, and securely share statutory Mental Health Act documentation across organisations involved in a patient’s care. It was implemented locally in SLaM from 24 March 2025, as part of a London-wide programme to improve the accuracy, timeliness and accessibility of MHA documentation.”

    Source location

    Response from South London and Maudsley NHS Foundation Trust
    Page 3 · response
    Published 19 June 2026

    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 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. Inner North London

    AI-generated summary

    Ronald Bainborough · 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

    Ronald Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting 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

    Delays in scheduling police execution of s135(1) warrants

    Wider context from the report

    “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed (2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest. (3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing. (4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled. (5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed. (6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm. ”

    Source location

    Ronald Bainborough · Prevention of Future Deaths report
    Page 2 · 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

    Delays in obtaining Magistrates Court hearings for s135(1) warrant applications

    Wider context from the report

    “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed (2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest. (3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing. (4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled. (5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed. (6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm. ”

    Source location

    Ronald Bainborough · 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

    Review police databases, conduct warrant-execution risk assessments, and record and supervisor-ratify controls on MHAA RA3 forms.

    Verbatim wording from the response

    “After a warrant is obtained under section 135(1) MHA 1983 information held on police databases about the person concerned is reviewed and a risk assessment is conducted. This enables officers to make an informed decision as to the police resources required to execute the warrant and ensure the safety of attending officers, healthcare professionals and the individual.”

    Source location

    Response from MPS
    Page 3 · response
    Published 25 February 2025

    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

    Review the corporate section 135 warrant process and incorporate matters raised in the report and identified learning.

    Verbatim wording from the response

    “The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this PFD report and learning identified will be incorporated into this.”

    Source location

    Response from MPS
    Page 4 · response
    Published 25 February 2025

    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

    Prioritise mental health warrant applications as priority-one work when allocating court time.

    Verbatim wording from the response

    “1) Listing is a judicial function and responsibility and arrangements for the operation of court lists are agreed with the judiciary and implemented by HMCTS. Arrangements for s.135 MHA warrants fall into these arrangements.”

    Source location

    Response from HMCTS
    Page 2 · response
    Published 25 February 2025

    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 remote mental health warrant applications with online self-service booking.

    Verbatim wording from the response

    “Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue.”

    Source location

    Response from HMCTS
    Page 2 · response
    Published 25 February 2025

    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 two separate remote warrant sessions daily on weekdays, with capacity exceeding typical demand.

    Verbatim wording from the response

    “The search warrant remote process was specifically designed to meet the needs and demands of the 32 London boroughs it serves. Since the inception of the remote process HMCTS has provided daily access to two separate, remote warrant sessions through Monday - Friday. The system is set up as an online self service, which means applicants can select hearing dates and times for their applications. Where sessions have been booked in advance, it is not unusual and indeed is commonplace for applicants to cancel slots, those slots are released back to the booking in system.”

    Source location

    Response from HMCTS
    Page 2 · response
    Published 25 February 2025

    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

    Maintain an open-door process allowing applicants to obtain immediate access to a courtroom for warrant applications.

    Verbatim wording from the response

    “Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue.”

    Source location

    Response from HMCTS
    Page 2 · response
    Published 25 February 2025

    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 out-of-hours access to the Judiciary for urgent mental health warrant applications seven days a week.

    Verbatim wording from the response

    “Additionally, the court provides a daily out of hours service for such applications, ensuring that the ability to apply for a mental health warrant is not hampered or impeded by a lack of access to the Judiciary. Again, there is an over provision of this service, to ensure that there are no delays in the out of hours operations.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    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 a central team and access routes through London magistrates’ courts for urgent warrant applications.

    Verbatim wording from the response

    “Had the application been considered and assessed as urgent, emergency procedures are well established for applications to be made within the working week – and out of hours on a 24/7 basis.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    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 practitioners with guidance describing booking arrangements for non-urgent, urgent and out-of-hours applications.

    Verbatim wording from the response

    “3) As above, the application was considered 3 working days after submission. Had the case been considered urgent, established procedures existed. Guidance to practitioners describing the scheme for booking non-urgent, urgent and out of hours applications had been provided by HMCTS. Regular inter-agency meetings provide for discussion about service provision. No concerns about service provision have ever been raised with HMCTS by NHS colleagues. The warrant courts at Westminster and Uxbridge provide sufficient supply of hearings for non-urgent applications based on data analysis and reviews over time. All London magistrates’ courts are available at any time for urgent applications. A central team provides access to urgent applications on request. This service is used relatively frequently by AMHPs.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    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

    Arrangements for executing warrants, including any fast-track procedure, do not fall within magistrates’ courts’ responsibilities.

    Verbatim wording from the response

    “4) This matter does not apply to the magistrates’ courts responsibilities.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    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

    Responsibility for applying to court for a section 135(1) warrant rests with Approved Mental Health Professionals, who are the only authorised applicants.

    Verbatim wording from the response

    “Applying for a warrant under Section 135(1) of the Mental Health Act (MHA) 1983”

    Source location

    Response from MPS
    Page 2 · response
    Published 25 February 2025

    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 application was non-urgent, was granted within three working days, and involved no delay attributable to court listing.

    Verbatim wording from the response

    “Evidence presented to the Inquest confirmed that the application was made on 18 August with an intended date for execution on 7 September 2023.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    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

    Existing booking, open-door, urgent and out-of-hours arrangements provide sufficient access to magistrates’ courts for mental health warrant applications.

    Verbatim wording from the response

    “2) Whilst there is a maximum number of hearing slots within the online booking system, the applicant’s access to a court hearing is not limited to the online booking slots. It is long established practice and procedure for mental health practitioners to attend court and apply for urgent mental health warrants.”

    Source location

    Response from HMCTS
    Page 3 · response
    Published 25 February 2025

    Open published response
  3. Inner North London

    AI-generated summary

    Zahra Sharif Mohamed · 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

    Zahra Sharif Mohamed, who had been detained under the Mental Health Act and sent on home leave, expressed suicidal thoughts and threatened to jump from the balcony of her fifth-floor flat. She jumped from the balcony on 12 October 2022 and died at the scene. The principal concerns were that a warrant to return her to hospital was not applied for, and that delays in obtaining and executing such warrants create a risk of patients harming themselves or others, including fatal harm.

    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

    Reliance on encouraging voluntary return before applying for a warrant

    Wider context from the report

    “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks. (2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant. (3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024. (4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court. (5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant. (6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm. ”

    Source location

    Zahra Sharif Mohamed · Prevention of Future Deaths report
    Page 2 · 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

    Risk of patients harming themselves or others before s135(2) warrant execution

    Wider context from the report

    “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks. (2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant. (3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024. (4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court. (5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant. (6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm. ”

    Source location

    Zahra Sharif Mohamed · 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

    Review the corporate section 135 warrant process and incorporate learning and matters raised in the prevention of future deaths report.

    Verbatim wording from the response

    “The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this PFD report and learning identified will be incorporated into this.”

    Source location

    Response from MPS
    Page 4 · response
    Published 25 February 2025

    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 an immediate police response is required while a section 135(2) warrant application awaits the court’s decision.

    Verbatim wording from the response

    “If a warrant appears to be the last option available, an application to the Magistrates’ Court will be made. If the application is made by an AMHP/duly authorised person a request for police attendance will be submitted.”

    Source location

    Response from MPS
    Page 2 · response
    Published 25 February 2025

    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

    Review police databases, conduct a risk assessment, and record and supervisor-ratify risks and control measures before executing section 135(2) warrants.

    Verbatim wording from the response

    “After a warrant is obtained, information held on police databases about the person concerned is reviewed and a risk assessment is conducted. This enables officers to make an informed decision as to the police resources required to execute the warrant and ensure the safety of attending officers, any healthcare professionals and the individual.”

    Source location

    Response from MPS
    Page 3 · response
    Published 25 February 2025

    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

    Operate the remote application and online self-service booking system for mental health warrants, with daily remote sessions and additional urgent access routes.

    Verbatim wording from the response

    “Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue.”

    Source location

    Response from HMCTS
    Page 2 · response
    Published 25 February 2025

    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

    Reiterate London magistrates’ court arrangements for routine, urgent and out-of-hours warrant applications to NHS colleagues.

    Verbatim wording from the response

    “6) Immediately on receipt of this report and in response to exchanges between HMCTS and NHS colleagues, we have re-iterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. A meeting to explore any concerns was arranged and held in July between senior HMCTS and NHS professionals. Continued communication of our arrangements will form part of our ongoing service and renewed commitment to partnership working to understand and resolve how serious misconceptions of service provision could have occurred amongst some AMHPs. We remain confident that our arrangements provide excellent access to AMHPs for urgent and emergency warrants.”

    Source location

    Response from HMCTS
    Page 4 · response
    Published 25 February 2025

    Open published response
  4. 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

    Failure to learn and correct identified unsafe beliefs about section 135 warrants

    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

    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

    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

    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

    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

    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

    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

    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
  5. Nottinghamshire

    AI-generated summary

    RYAN JAMES VOUT · 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

    Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.

    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

    Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant

    Wider context from the report

    “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant; ”

    Source location

    RYAN JAMES VOUT · 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

    Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant

    Wider context from the report

    “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant. ”

    Source location

    RYAN JAMES VOUT · 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

    Launch the Mental Health Crisis Care Concordat establishing agreed protocols for local mental health crisis responses.

    Verbatim wording from the response

    “You may also be aware that we launched the Mental Health Crisis Care Concordat in 2014 which has been signed by all services, including the police service and the NHS, involved in providing care for people who may experience a mental health crisis. The Crisis Care Concordat is clear that every local area should have agreed clear protocols for local services responding to a mental health crisis which clearly identify roles and responsibilities. Every local area has a Mental Health Crisis Care Concordat Action Plan in place and we continue to work with these areas to embed and improve their plans.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 4 · response
    Published 12 February 2018

    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

    Work with local areas to embed and improve their Mental Health Crisis Care Concordat action plans.

    Verbatim wording from the response

    “You may also be aware that we launched the Mental Health Crisis Care Concordat in 2014 which has been signed by all services, including the police service and the NHS, involved in providing care for people who may experience a mental health crisis. The Crisis Care Concordat is clear that every local area should have agreed clear protocols for local services responding to a mental health crisis which clearly identify roles and responsibilities. Every local area has a Mental Health Crisis Care Concordat Action Plan in place and we continue to work with these areas to embed and improve their plans.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 4 · response
    Published 12 February 2018

    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

    Develop a more robust joint process for communicating demographic and essential risk information between AMHPs and police before s135 warrant execution.

    Verbatim wording from the response

    “A more robust process for communicating demographics and essential risk information in relation to the s135 (1) warrant between AMHPs and the Police has been developed jointly.”

    Source location

    2017-0376-Response-by-Nottinghamshire-County-Council
    Page 2 · response
    Published 12 February 2018

    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

    Introduce a typewritten s135 information document for magistrate completion and electronic transmission to police, including recent risk assessments and environmental factors.

    Verbatim wording from the response

    “This will include a typewritten document that is completed initially for the magistrate and then sent electronically by the AMHP when requesting police assistance under s.135 (1). This will ensure that clear communication to all agencies including recent risk assessments and environmental factors are taken in to account with regard to the specifics of the situation.”

    Source location

    2017-0376-Response-by-Nottinghamshire-County-Council
    Page 2 · response
    Published 12 February 2018

    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

    Operational discharge and conveyance arrangements are matters for local health services, commissioners, providers, ambulance services and police.

    Verbatim wording from the response

    “The other two areas of concern fall to health services. The matters raised are operational and relate to the Nottinghamshire Healthcare NHS Foundation Trust and the ambulance service and I trust the responses you will receive from those organisations will be helpful. My response will focus on the national policy expectations in relation to the issues you have raised.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 1 · response
    Published 12 February 2018

    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

    Pre-booking an ambulance for section 135 or 136 attendances has always been available, although operational demand affects prioritisation.

    Verbatim wording from the response

    “• The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant”

    Source location

    2017-0376-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 12 February 2018

    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

    Police risk assessment before executing a section 135 warrant is outside the respondent’s remit and will not be addressed.

    Verbatim wording from the response

    “Your report raises three areas of concern. Firstly, around discharge planning; secondly, the ability to pre-book appropriate transport for conveyance of a patient being sectioned under the Mental Health Act; and thirdly, the risk assessment conducted by the police prior to the exercise of a section 135 warrant.”

    Source location

    2017-0376-Response-by-Department-of-Health
    Page 1 · response
    Published 12 February 2018

    Open published response
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Data last updated 7 September 2026