PFD report

Joshua Adey Rennard · Prevention of Future Deaths report

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Issued 7 Mar 2022•South Yorkshire (Western)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Delays in promptly progressing recommendations for section assessment
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessment
  2. Failure to protect people with mental illness while awaiting section assessment
    Part of recurring concern: Failure to ensure timely and appropriate Mental Health Act assessmentPart of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pendingPart of recurring concern: Unreliable interim mental health support during care transitions
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Delays in promptly progressing recommendations for section assessment

Wider context from the report

“5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future. 5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment.

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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 to protect people with mental illness while awaiting section assessment

Wider context from the report

“5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future. 5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely and appropriate Mental Health Act assessment; Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending; Unreliable interim mental health support during care transitions.

Open source report
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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