Mental Health Act assessors

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First report 25 Oct 2016•Latest report 25 Oct 2016

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
1

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 Mental Health Act assessors linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Richard Walsh · 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

    Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion

    Wider context from the report

    “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”
    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of detained organisations to pass risk information consistently between one another

    Wider context from the report

    “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate nurse assessment of fitness for segregation

    Wider context from the report

    “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support. ”
    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an agreed system for transferring health care information from police stations or courts to prisons

    Wider context from the report

    “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate standard of Mental Health Act assessments

    Wider context from the report

    “2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed. ”
    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 Mental Health Act assessors; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear responsibility for passing or seeking relevant information

    Wider context from the report

    “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
    Open source report
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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