Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 21
Thames Valley Police Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.
View source
Thames Valley Police Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.
View source
Thames Valley Police Become a signatory to the local Crisis Care Concordat declaration and action plan once the agreement is reached.
View source
Thames Valley Police Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.
View source
Thames Valley Police Work with partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.
View source
British Transport Police Include proactive interagency dialogue requirements in relevant BTP training.
View source
British Transport Police Provide suicide-prevention and mental-health training to control-room staff and new officers, incorporating lessons from the inquest.
View source
British Transport Police Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
View source
British Transport Police Ask for removal of the recommendation that police contact an AMHP before arrival at a place of safety during the Mental Health Act Code review.
View source
British Transport Police Provide frontline training on vulnerable people, mental-health crisis, suicide prevention and relevant policies and processes.
View source
British Transport Police Implement any Independent Police Complaints Commission recommendations concerning the officers’ actions and promulgate resulting lessons throughout the force.
View source
British Transport Police Detail all places of safety in the Force Control Room Gazetteer to speed care for Section 136 detainees.
View source
Royal Berkshire NHS Foundation Trust Disseminate the revised protocol to senior staff and crisis-care personnel across participating agencies.
View source
Royal Berkshire NHS Foundation Trust Hold interagency meetings to identify knowledge gaps and improve joint working on Section 136 patient care.
View source
Royal Berkshire NHS Foundation Trust Consult agencies on the revised interagency Section 136 protocol before requiring participating agencies to sign it.
View source
Royal Berkshire NHS Foundation Trust Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
View source
Royal Berkshire NHS Foundation Trust Display the approved Section 136 flowchart prominently in the A&E department.
View source
Royal Berkshire NHS Foundation Trust Provide cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
View source
Royal Berkshire NHS Foundation Trust Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
View source
Royal Berkshire NHS Foundation Trust Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
View source
Royal Berkshire NHS Foundation Trust Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
View source
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of joint working to address high self-harm risk promptly
Wider context from the report “(3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Insufficient knowledge and understanding of the interagency mental health working protocol
Wider context from the report “(2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley Area"
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Breakdown of the British Transport Police chain of command for detention responsibilities
Wider context from the report “(1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
Wider context from the report “There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment .
” 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 Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.
Verbatim wording from the response “The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric liaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However, once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness. Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.
Verbatim wording from the response “Thames Valley Police were not directly involved in the original incident involving Mr Church, his detention under S136 Mental Health Act nor his subsequent care prior to his death on 13th May 2011. However, as the force lead in Mental Health for Thames Valley Police I take responsibility for co-ordinating the publication of an interagency joint working protocol for managing mental health in the Thames Valley Area. This protocol was subject to discussion during the inquest.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 Become a signatory to the local Crisis Care Concordat declaration and action plan once the agreement is reached.
Verbatim wording from the response “In addition to this the Chief Executive of Berkshire NHS Foundation Trust, Mr Julian Emms, has already consulted with relevant organisations to agree a” Source location 2014-0331-Response-by-Thames-Valley-Police
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 Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.
Verbatim wording from the response “While British Transport Police have indicated that they are unable to be signatories to individual protocols as they are a National Force, Thames Valley Police will make every effort to ensure their awareness and understanding of the Thames Valley protocol.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.
Verbatim wording from the response “The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric liaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However, once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness. Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 Include proactive interagency dialogue requirements in relevant BTP training.
Verbatim wording from the response “I acknowledge that regular and detailed communication with the other agencies involved in Mr Church’s case could have led to his greater care whilst at the hospital. Further, that additional care staff may have been provided had they been aware that he was with only one officer. This issue of ‘proactively maintaining dialogue’ is covered in the ‘Briefing Note – New Policy for London Section 136, (page 60) under the heading ‘Triage Risk Assessment/Triage Psychiatric Assessment’. This element of that briefing note is now included in all relevant BTP training.” Source location 2014-0331-Response-by-British-Transport-Police
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 suicide-prevention and mental-health training to control-room staff and new officers, incorporating lessons from the inquest.
Verbatim wording from the response “• A two hour input to all Force control room staff on Suicide Prevention and Mental Health issues; the officer in charge of this training has been fully briefed on the findings from Mr Church’s inquest and will incorporate the lessons learned into this presentation” Source location 2014-0331-Response-by-British-Transport-Police
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 Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
Verbatim wording from the response “In summary, the break down in the chain of command is being addressed as a conduct issue and I am confident that there is no systemic failing in this area. With regards to the other concern highlighted, the BTP Manual of Guidance now includes the following:” Source location 2014-0331-Response-by-British-Transport-Police
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 Ask for removal of the recommendation that police contact an AMHP before arrival at a place of safety during the Mental Health Act Code review.
Verbatim wording from the response “I am aware that the Mental Health Act Code of Practice is currently being reviewed and a draft has been circulated for consultation. British Transport Police will be asking for the recommendation for Police to call the AMHP prior to arrival at a place of safety to be removed, as it is impractical and more likely to lead to confusion and delay in provision of an early assessment for a patient in similar circumstances to Mr Church.” Source location 2014-0331-Response-by-British-Transport-Police
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 frontline training on vulnerable people, mental-health crisis, suicide prevention and relevant policies and processes.
Verbatim wording from the response “I have committed training resources to front-line officers in the following areas:” Source location 2014-0331-Response-by-British-Transport-Police
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 any Independent Police Complaints Commission recommendations concerning the officers’ actions and promulgate resulting lessons throughout the force.
Verbatim wording from the response “I recognise that this breakdown in the chain of command ultimately had implications for the care of Mr Church but I do not believe that this is a systematic failing in BTP processes. Rather, this was an isolated incidence of misconduct. My Professional Standards Department referred this incident to the Independent Police Complaints Commission in 2011 and we currently await the outcome of that investigation. I will ensure that any recommendations in relation to the actions of ████████ and ████████ are implemented and that any lessons learned are appropriately promulgated throughout the force.” Source location 2014-0331-Response-by-British-Transport-Police
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 Detail all places of safety in the Force Control Room Gazetteer to speed care for Section 136 detainees.
Verbatim wording from the response “Whilst it would be a vast undertaking to be aware of each and every local protocol from the 56 Statutory Mental Health Trusts and the 40 Mental Health Trust providers in England and Wales, we are nevertheless in the process of detailing all ‘places of safety’ on our Force Control Room Gazetteer to speed up the process of care for Section 136 detainees.” Source location 2014-0331-Response-by-British-Transport-Police
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 Disseminate the revised protocol to senior staff and crisis-care personnel across participating agencies.
Verbatim wording from the response “1. In relation to the concern that there was insufficient knowledge and understanding amongst members of the Psychiatric Liaison Service and the Royal Berkshire Hospital with regards the interagency working protocol for the management of mental health in the Thames Valley area, an interagency meeting was held on 24 September 2014 to identify the gaps in the various agencies’ knowledge and understanding with a plan put in place to revise the current protocol and to hold a consultation. The protocol will be sent to all senior staff involved in crisis management of these patients and there will be training in the use of the protocol for all of the agencies.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Hold interagency meetings to identify knowledge gaps and improve joint working on Section 136 patient care.
Verbatim wording from the response “The meeting was held to discuss the concerns raised by the coroner. With regards the first area of concern, this was within the control of the British Transport Police and so we did not discuss it in any depth. We understand a separate response has been sent.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Consult agencies on the revised interagency Section 136 protocol before requiring participating agencies to sign it.
Verbatim wording from the response “A revised version of the protocol is currently being finalised by Thames Valley Police under the supervision of ████████, Inspector, Thames Valley Police, and Mental Health Lead. ████████, Mental Health Act Administrator, is also assisting with the revision of the protocol. The intention is for the protocol to be clearer and easier to understand/ navigate so that the agencies can work together more effectively and are able to identify their individual roles with regards patients who are admitted to the Trust under Section 136 of the Mental Health Act 1983.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
Verbatim wording from the response “the patient to be assessed with either admission to the Trust with support from PMS or a transfer to a place of safety e.g. Prospect Park Hospital. The flowchart has been finalised and approved by the A&E Clinical Governance Team. The Royal Berkshire NHS Foundation Trust has also adopted the assessment forms for Section 136 monitoring from the mental health Trust so that the key information is gathered on admission and the nursing staff are able to identify whether the AMHP has been informed of the need for assessment at an early stage. There will be a further check made by the PMS who will advise the A&E staff regarding the management of the Section 136 patient in the A&E Department. PMS will also check whether the AMHP has been contacted. Copies of the assessment form for Section 136 will be sent to the RBH Mental Health Coordinator so that care can be audited.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Display the approved Section 136 flowchart prominently in the A&E department.
Verbatim wording from the response “In the meantime, the Royal Berkshire NHS Foundation Trust has finalised and approved a flowchart that will be prominently displayed in the A&E department. It is intended that the flowchart will be in place in the A&E department before 26 November 2014 and that staff will have received training with regards use of the flowchart and the S136 monitoring forms by the end of November 2014.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
Verbatim wording from the response “There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
Verbatim wording from the response “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
Verbatim wording from the response “2. The trust has a flowchart which identifies the steps that need to be taken from the point of admission to A&E and identifies the role of the psychological medicine service (PMS) at the Trust who will advise A&E on the management of the patient in the A&E Department. They will also check that AMHP has been called which was a particular area of concern.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
Verbatim wording from the response “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 British Transport Police cannot sign individual protocols because it is a national force.
Verbatim wording from the response “While British Transport Police have indicated that they are unable to be signatories to individual protocols as they are a National Force, Thames Valley Police will make every effort to ensure their awareness and understanding of the Thames Valley protocol.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 disseminating and training staff on the protocol lies with the individual organisations, not Thames Valley Police.
Verbatim wording from the response “The specific concern raised by Mr Sidhu that related to the protocol suggests that there was insufficient knowledge and understanding about it among staff members of the psychiatric liaison service and the Royal Berkshire Hospital. Thames Valley Police has no direct responsibility or influence for their understanding as responsibility for dissemination and training of the protocol lies with the individual organisations concerned. However, once the amended version has been agreed, Thames Valley Police is committed to work together with the other organisations named within the Regulation 28 report to assist with joint training and awareness. Our own staff will be informed of the need to ensure that other organisations are aware of its existence whenever an incident occurs and to support partner agencies in understanding the individual responsibilities.” Source location 2014-0331-Response-by-Thames-Valley-Police
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 chain-of-command breakdown was an isolated misconduct incident, not evidence of a systemic failing in British Transport Police processes.
Verbatim wording from the response “I recognise that this breakdown in the chain of command ultimately had implications for the care of Mr Church but I do not believe that this is a systematic failing in BTP processes. Rather, this was an isolated incidence of misconduct. My Professional Standards Department referred this incident to the Independent Police Complaints Commission in 2011 and we currently await the outcome of that investigation. I will ensure that any recommendations in relation to the actions of ████████ and ████████ are implemented and that any lessons learned are appropriately promulgated throughout the force.” Source location 2014-0331-Response-by-British-Transport-Police
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 Health professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.
Verbatim wording from the response “My view is supported by reference to a recent meeting of the Mental Health Partnership Board for London, which includes CEOs of the London Mental Health Trusts. At that meeting the question of whose role it was to call the AMHP following a S136 detention delivered a unanimous response; that it was the role of the health professionals as the police would not have access to up to date information. The Board has recently launched a new policy for S136 and S135 arrangements in” Source location 2014-0331-Response-by-British-Transport-Police
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 British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.
Verbatim wording from the response “It was acknowledged at the Inquest that British Transport Police was not a signatory to the joint interagency protocol, but officers giving evidence accepted that they would try to work to the aims where possible. I endorse this aspiration but must highlight the impracticalities of British Transport Police being able to achieve this in every case.” Source location 2014-0331-Response-by-British-Transport-Police
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 A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.
Verbatim wording from the response “In the meantime, the two senior consultants from the A&E department, ████████ and the Matron ████████ attended the inter-agency meeting at the Trust on 24 September and have taken the message back to the A&E department that they should be liaising with the PMS at the Trust who, although they will not take responsibility for the patient, will advise on their management and contacting the AMHP if that has not already been done. There is therefore a mechanism whereby the A&E staff will be aware that it is their responsibility to check that the AMHP has been contacted and if for any reason it is not done for the PMS to make sure that contact is made at the earliest opportunity.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 the police chain-of-command concern lies with British Transport Police, which is addressing it separately.
Verbatim wording from the response “The meeting was held to discuss the concerns raised by the coroner. With regards the first area of concern, this was within the control of the British Transport Police and so we did not discuss it in any depth. We understand a separate response has been sent.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 British Transport Police cannot sign local protocols because it is a national force, but has agreed to abide by the protocol.
Verbatim wording from the response “There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
Open published response
Pin
Get email alerts
Request correction
Information checked against the published report and official responses