Central Bedfordshire Council

Local government · English unitary authority

Pin Request correction

First report 29 Jan 2015•Latest report 5 Jan 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Central Bedfordshire Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    James EMMERSON · 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

    James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.

    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. The report was sent to Central Bedfordshire Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide AMHP assessment before discharge from section 136 detention

    Wider context from the report

    “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”). The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders. Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital. Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”. “The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment. “The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.” Jamie was never examined by an AMPH only by a lone section 12 approved junior doctor and he was discharged from his s.136. In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.” This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises. I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central Bedfordshire Council; that does not assign responsibility.

    PFD Monitor interpretation

    Ambiguity in guidance on required AMHP assessment under section 136

    Wider context from the report

    “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”). The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders. Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital. Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”. “The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment. “The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.” Jamie was never examined by an AMPH only by a lone section 12 approved junior doctor and he was discharged from his s.136. In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.” This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises. I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to. ”
    Open source report

  2. Bedfordshire and Luton

    AI-generated summary

    Margaret Emily Flemming · 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

    Margaret Emily Flemming, a care-home resident with dementia, was seen by a doctor and prescribed antibiotics over 17–18 January 2015, and died peacefully at the care home the following day. The report raised concerns about delays in completing a Best Interests Assessment after an urgent Deprivation of Liberty Safeguarding Authorisation request, while she remained vulnerable and confused.

    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. The report was sent to Central Bedfordshire Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange urgent assessment of confused people

    Wider context from the report

    “2. The Local Authority were aware for a long period of time that the deceased had become confused and required urgent assessment. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Central Bedfordshire Council; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in completing Best Interests Assessments following urgent Deprivation of Liberty Safeguarding Authorisation requests

    Wider context from the report

    “1. An urgent Request for a Deprivation of Liberty Safeguarding Authorisation was placed with Central Bedfordshire Council on 8th October 2014 and yet the Best Interests Assessment did not take place until 7th January 2015. The deceased remained vulnerable throughout this period. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026