PFD report

Jason Basalat · Prevention of Future Deaths report

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Issued 27 Nov 2017•Milton Keynes

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings
    Part of recurring concern: Unreliable Saturday mental health assessment service for magistrates' court defendants
  2. Failure of the court to inform the prison about a defendant's mental illness and related problems
    Part of recurring concern: Unreliable court-to-prison transfer information
  3. Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances
    Part of recurring concern: Unreliable court-to-prison transfer information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Contact the national police lead on custody to suggest reviewing the Person Escort form against Authorised Professional Practice guidance.

    Stated by Northamptonshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 27 February 2018.
  2. Action

    Remind custody officers and staff to follow guidance on completing Person Escort Records and attaching relevant documentation.

    Stated by Northamptonshire PoliceStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.
  3. Action

    Deliver and evaluate training to magistrates on procedures for identifying vulnerable defendants and obtaining assessments.

    Stated by Northamptonshire Magistrates’ CourtsStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    The existing Person Escort Form and round-the-clock switchboard provided sufficient risk information and a route for receiving staff to seek clarification.

    Stated by Northamptonshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings

Wider context from the report

“(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture. (2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment. (3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. ”

Is this part of a recurring concern?

Yes — Unreliable Saturday mental health assessment service for magistrates' court defendants.

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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

Failure of the court to inform the prison about a defendant's mental illness and related problems

Wider context from the report

“(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture. (2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment. (3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. ”

Is this part of a recurring concern?

Yes — Unreliable court-to-prison transfer information.

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

Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances

Wider context from the report

“(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture. (2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment. (3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner. ”

Is this part of a recurring concern?

Yes — Unreliable court-to-prison transfer information.

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

Contact the national police lead on custody to suggest reviewing the Person Escort form against Authorised Professional Practice guidance.

Verbatim wording from the response

“4.17 Further, contact will be made with the national police lead on Custody to suggest a review of the PER form to ensure it reflects the guidance in the Authorised Professional Practice.”

Source location

2017-0423-Response-by-Northampton-Police
Page 8 · response
Published 27 February 2018

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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

Remind custody officers and staff to follow guidance on completing Person Escort Records and attaching relevant documentation.

Verbatim wording from the response

“4.16 However, the Chief Constable confirms that Custody officers and staff have been reminded of the guidance in relation to the completion of PER forms and in respect of ensuring any relevant additional documentation accompanies them.”

Source location

2017-0423-Response-by-Northampton-Police
Page 8 · response
Published 27 February 2018

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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

Deliver and evaluate training to magistrates on procedures for identifying vulnerable defendants and obtaining assessments.

Verbatim wording from the response

“33. As outline above the court does have procedures in place to ensure that vulnerable defendants are identified to the court; see appendix D and E. Magistrates have been made aware of these procedures, see appendix F and training has been delivered to magistrates and evaluated, see appendix G.”

Source location

BASALAT-Response
Page 6 · response
Published 27 February 2018

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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 the liaison team’s information leaflet to legal advisers and remind them to forward CPN1 forms or endorse warrants and attach available MG5s.

Verbatim wording from the response

“43. Legal advisers have been issued with the above Team’s information leaflet and reminded of the need to forward the CPN1 form to the relevant custodial establishment if a vulnerable adult is remanded into custody. Failing this, to endorse the warrant and forward the MG5, if available.”

Source location

BASALAT-Response
Page 5 · response
Published 27 February 2018

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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

Liaise with criminal justice partners to review CPN procedures and consider information forwarded to prisons when vulnerable adults are remanded.

Verbatim wording from the response

“42. The court will liaise with the Criminal Justice Liaison and Diversion Team, to review the robustness of the present CPN procedures and consider what further information should be forwarded to a prison should a vulnerable adult be remanded to it.”

Source location

BASALAT-Response
Page 5 · response
Published 27 February 2018

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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

Maintain procedures for identifying vulnerable defendants and obtaining mental health assessments.

Verbatim wording from the response

“40. The court does have in place procedures to ensure vulnerable adults are identified and assessments undertaken.”

Source location

BASALAT-Response
Page 5 · response
Published 27 February 2018

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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 existing Person Escort Form and round-the-clock switchboard provided sufficient risk information and a route for receiving staff to seek clarification.

Verbatim wording from the response

“The PER form provides staff transporting and receiving detainees with all necessary information. This includes any risks or vulnerabilities that the person may present.”

Source location

2017-0423-Response-by-Northampton-Police
Page 7 · response
Published 27 February 2018

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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 custody record is intended to document treatment in police custody, not provide a full picture of the investigation, evidence or detainee’s circumstances.

Verbatim wording from the response

“4.7 The Custody Record is a document which the police are required to maintain to record certain decisions made pursuant to section 37 of the Police and Criminal Evidence Act 1984 and paragraph 2.1 of Code of Practice C referred to above.”

Source location

2017-0423-Response-by-Northampton-Police
Page 6 · response
Published 27 February 2018

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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 concern about Magistrates’ Court procedure falls outside the matters addressed in this response.

Verbatim wording from the response

“2.1.2 Point (2) appears to relate solely to the procedure before the Magistrates’ Court and is not addressed in this response.”

Source location

2017-0423-Response-by-Northampton-Police
Page 2 · response
Published 27 February 2018

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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 format of the Warrant of Remand is not a police matter, so no comment is made on it.

Verbatim wording from the response

“4.6 The format of the Warrant of Remand is not a matter for the police and the Chief Constable makes no comment on that issue.”

Source location

2017-0423-Response-by-Northampton-Police
Page 6 · response
Published 27 February 2018

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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

Direct prison contact and prisoner risk assessment are not functions of the court, unlike those of a custodian.

Verbatim wording from the response

“28. It is not normal practice for a legal adviser to directly contact any prison establishment. Unlike any custodian of a detained person the court does not undertake a risk assessment of a prisoner. The police had completed a Person Escort Record form and this would have accompanied Mr Basalat.”

Source location

BASALAT-Response
Page 4 · response
Published 27 February 2018

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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 procedures identify vulnerable detained adults and provide for CPN assessment and reporting when concerns arise.

Verbatim wording from the response

“21. The court does have in place a process to provide it with information when vulnerable adults are detained in custody. This is initiated by the police when they have concerns that such an adult is being detained; they will request a CPN to attend the custody suite and carry out an assessment. The assessment is then recorded on form CPN1 and this is then forwarded to the court when the defendant appears before them in custody, or at a later date if the defendant is released to appear on a subsequent occasion.”

Source location

BASALAT-Response
Page 3 · response
Published 27 February 2018

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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

Additional mental-health assessment was not considered necessary because the police mental-health team cleared attendance and the CPN identified no concerns.

Verbatim wording from the response

“24. In any event, on this occasion, the court was advised that Mr Basalat had been given the all clear by the police doctor/mental health team to attend court. There were no concerns about Mr Basalat from the Community Psychiatric Nurse who had assessed him in custody.”

Source location

BASALAT-Response
Page 4 · response
Published 27 February 2018

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Implement the in-court computer system to generate warrants containing the full charge.

    Stated by Northamptonshire Magistrates’ CourtsStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The charge format is prescribed nationally, so it cannot be altered to include a narrative or summary of supporting evidence.

    Stated by Northamptonshire PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 in-court computer system to generate warrants containing the full charge.

Verbatim wording from the response

“14. HMCTS is implementing an ‘in-court’ computer system which requires the legal adviser, rather than support staff, to enter the court result. This will generate a warrant with the full charge but will not include the circumstances of the offence.”

Source location

BASALAT-Response
Page 2 · response
Published 27 February 2018

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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 charge format is prescribed nationally, so it cannot be altered to include a narrative or summary of supporting evidence.

Verbatim wording from the response

“4.3 The format of the charge of Dangerous Driving is prescribed by a national code to ensure a consistency of approach. The purpose of a charge is to provide an accused person with sufficient information about the nature of the charge laid against them to enable them to determine whether or not to admit or deny guilt. It will not contain a narrative or summary of the evidence supporting the charge; that information falls to be disclosed in the course of any subsequent proceedings.”

Source location

2017-0423-Response-by-Northampton-Police
Page 5 · response
Published 27 February 2018

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

Data last updated 7 September 2026