Concerns raised 2
Failure of police training on ambulance conveyance for s.136 detainees View source Lack of joined-up agency policy for s.136 detention and conveyance View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Kaine Regan FLETCHER · Prevention of Future Deaths report
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Report summary
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” Source location Kaine Regan FLETCHER · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” Source location Kaine Regan FLETCHER · Prevention of Future Deaths report
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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 Support forces to develop local protocols with partner agencies.
Verbatim wording from the response “• Support forces in developing local protocols with partner agencies” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue comprehensive guidance on safe conveyance, including health-based vehicle provision and arrangements for section 136 detainees.
Verbatim wording from the response “NHS England has issued comprehensive guidance, including on the conveyance of individuals detained under section 136, which sets out that:” Source location Response from Department for Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational and local partnership concerns are being addressed by Nottinghamshire Police, which is providing the full response.
Verbatim wording from the response “We have carefully considered the matters of concern raised in your Regulation 28 report. This response outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect of the Mental Health Act. In relation to the operational elements and local partnership working, we have been in contact with Nottinghamshire Police and understand that a number of measures are being implemented and a full response to the concerns you have raised is being provided.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agreeing a joint agency policy for section 136 detentions is the responsibility of East Midlands Ambulance Service and the police.
Verbatim wording from the response “Your concern about the lack of agreed joint agency policy between East Midlands Ambulance Service and the police on section 136 detentions is a matter for those organisations.” Source location Response from Department for Health and Social Care
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7 Mar 2019 Simon Robinson · Prevention of Future Deaths report Oxfordshire
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Concerns raised 1
Inadequate partnership agreement coverage for mental health crisis situations View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Thames Valley Police
Review the interagency partnership protocol to address crisis-response gaps.
View source
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Simon Robinson · 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
Simon Robinson died at home on 2 February 2018 after stabbing himself in the neck with a kitchen knife during a psychotic episode. His wife’s 999 call requesting police attendance was incorrectly graded, resulting in a delayed response. The principal concern was that the partnership agreement between police and mental health services did not adequately cover mental health crises in private places, including the expected initial police response when there is a fear for welfare or safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate partnership agreement coverage for mental health crisis situations
Wider context from the report “The concern that I have is mirrored in Chief Superintendent Bunt’s statement paragraph 57 where it states that the current partnership agreement does not adequately cover incidents such as this one . The problem is not uncommon situation where a person is experiencing a mental health crisis and there is an imminent need for agencies to respond. If the person is experiencing the mental health crisis is in their home or another private place, police powers are limited. I recognise there is a requirement to work in partnership with other agencies but the primary responsibility to respond when there is a fear for welfare or safety rests with the police. It should be the expectation therefore that the police will respond initially to deal with matters until other agencies are able to respond and take over if appropriate. It is concerning that there is a gap in the partnership agreement for a crisis situation such as this .
” Source location Simon Robinson · Prevention of Future Deaths report
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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 interagency partnership protocol to address crisis-response gaps.
Verbatim wording from the response “The Interagency Partnership Agreement (Protocol), between Thames Valley Police (TVP) and Social Care agencies has been carefully considered and reviewed to address the concerns which have been raised.” Source location 2019-0176-Response-by-Thames-Valley-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Multi-agency Protocol changes cannot be implemented until all parties have fully agreed them.
Verbatim wording from the response “A strategic Mental Health partners meeting was held on 2nd April 2019. The recommended amendments were disseminated to all relevant Mental Health and NHS Agencies for consultation at this meeting. A response is expected from all agencies by 30th April 2019. The Protocol must be fully agreed by all parties before any changes are implemented.” Source location 2019-0176-Response-by-Thames-Valley-Police
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29 Apr 2015 Finnulla Catherine MARTIN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Confusion about voluntary attendance of patients with mental health needs accompanied by police View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Finnulla Catherine MARTIN · 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
Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “2. As I have indicated above, the confusion surrounding voluntary attendance of a patient with mental health needs accompanied by the police , suggests a multi agency discussion and agreement would be beneficial.
” Source location Finnulla Catherine MARTIN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and finalise Emergency Department guidelines for patients brought by police.
Verbatim wording from the response “a) Development of care guidelines relating to patients brought into the Emergency Department by the police.” Source location 2015-0173-Whittington-Health-NHS-Trust
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20 Mar 2015 Kingsley Burrell · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association of Ambulance Chief Executives Department of Health and Social Care National Police Chiefs’ Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Association of Ambulance Chief Executives
Continue working with police, Home Office and Department of Health partners to improve ambulance response speed and ambulance conveyance under Section 136.
View source
Association of Ambulance Chief Executives
Work with the National Police Chiefs Council to ensure ambulances are requested for Section 136 incidents and reduce police conveyance.
View source
Department of Health and Social Care
Develop further guidance and training with police, professional bodies and mental health trusts to support local restraint protocols.
View source
Department of Health and Social Care
Revise the Mental Health Act Code of Practice to provide statutory guidance on restrictive practices and restraint.
View source
National Police Chiefs’ Council
Examine the role, legal basis, responsibility and safe practice for police involvement in mental health restraint through an expert reference group.
View source
National Police Chiefs’ Council
Report the expert reference group’s initial findings on the role of police in mental health settings by the end of the calendar year.
View source
National Police Chiefs’ Council
Issue national instructions requiring monitoring and review of police requests to mental health environments, with escalation and supervisory involvement whenever restraint occurs.
View source See 4 more actions
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Kingsley Burrell · 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
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder
Wider context from the report “(3) This case has resulted in a multi-agency review of how patients are managed between the services when crisis occurs. A new conveying of patients policy has been devised. Critically police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward. My concern is that this is not reflected nationally . Chief Inspector ███████ at West Midlands Police can provide full details of the policy.
” Source location Kingsley Burrell · Prevention of Future Deaths report
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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 working with police, Home Office and Department of Health partners to improve ambulance response speed and ambulance conveyance under Section 136.
Verbatim wording from the response “As a consequence ambulance trusts in England introduced new protocols in April 2014 designed to improve the speed of response to patients detained under Section 136 of the Mental Health Act in order to offer a clinical assessment more quickly and to arrange subsequent conveyance to a place of safety more efficiently. Data for 2014/15 indicates that there have been encouraging improvements with 74% of incidents where the police requested an ambulance receiving a response within 30 minutes. AACE continue to work with the NPCC, Home Office and the Department of Health to drive further improvements in both the speed of ambulance response and the proportion of patients conveyed by ambulance rather than police vehicles.” Source location 2015-0472-Response-by-Association-of-Ambulance-Chief-Executives
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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 the National Police Chiefs Council to ensure ambulances are requested for Section 136 incidents and reduce police conveyance.
Verbatim wording from the response “In the respect of the latter recent Home Office data indicates that for Section 136 where patients were conveyed by the Police 43% of cases were due to risk or behavioural issues and in 32% of cases no ambulance had been requested by the police. AACE continue to work with the NPCC to ensure that an ambulance is always requested and that police conveyance is reduced to as low a rate as possible.” Source location 2015-0472-Response-by-Association-of-Ambulance-Chief-Executives
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop further guidance and training with police, professional bodies and mental health trusts to support local restraint protocols.
Verbatim wording from the response “Both the Code and the guidance make clear that all types of restraint should be used for the least amount of time needed to manage risks to the individual and others. Department officials continue to work with the police, the Royal Colleges of Nurses and Psychiatrists, and Mental Health Trusts to develop further guidance and training to support local protocols, so that all partners are clear about what should happen in these circumstances.” Source location 2015-0472-Response-by-Department-of-Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Mental Health Act Code of Practice to provide statutory guidance on restrictive practices and restraint.
Verbatim wording from the response “On restraint, both statutory and non-statutory guidance exists. The Mental Health Act 1983 Code of Practice (the Code) was revised in 2015 and provides statutory guidance on the appropriate use of restrictive practices that protect the dignity and safety of patients. The Code is clear that any restraint should be the least restrictive,” Source location 2015-0472-Response-by-Department-of-Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Examine the role, legal basis, responsibility and safe practice for police involvement in mental health restraint through an expert reference group.
Verbatim wording from the response “In this tragic case, police officers were called in to a mental health environment to effect restraint upon a patient. Aside from the moral and ethical issues pertaining to police officers entering into a care environment to affect this type of force, I am examining the whole issue of the role of police in these types of circumstances and indeed whether this is simply an issue of a lack of capability, capacity and training for health practitioners rather than that it is and should be presumed a police matter. I hope you will be reassured to know that to this end I have been working with the College of Policing and have instigated an expert reference group, chaired by Lord Alex Carlile, to ascertain not only the legal platform upon which activities should sit, but further who should effect them and what is defined as safe practice across all public service disciplines.” Source location 2015-0472-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report the expert reference group’s initial findings on the role of police in mental health settings by the end of the calendar year.
Verbatim wording from the response “Chief Inspector Russell has cited my own national instruction to Chief Officers in respect of the monitoring and reviewing of all service requests to mental health environments, and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in a health environment whatever the circumstances.” Source location 2015-0472-Response-by-Metropolitan-Police
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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 national instructions requiring monitoring and review of police requests to mental health environments, with escalation and supervisory involvement whenever restraint occurs.
Verbatim wording from the response “Chief Inspector Russell has cited my own national instruction to Chief Officers in respect of the monitoring and reviewing of all service requests to mental health environments, and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in a health environment whatever the circumstances.” Source location 2015-0472-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local policies and crisis plans provide the arrangements for cross-agency mental health crisis responses rather than a single national system.
Verbatim wording from the response “You highlight the need for cross-agency working to safely manage people being moved between services when a mental health crisis occurs and when police attend a health setting. The Code states local policies should be in place between providers, the police and other agencies with protocols covering all aspects of the use of section 135 and 136 powers. Sections 135 and 136 give the police powers to temporarily move people, who appear to be suffering from a mental disorder, and who need urgent care, to a ‘place of safety’ so that a mental health assessment can be carried out and appropriate arrangements made for care. Local policies should include arrangements for police attend a health-based setting and transporting people between places of safety.” Source location 2015-0472-Response-by-Department-of-Health
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.