The Office of the Chief Coroner’s website having been recently updated, here is a selection of PFD notices which have a relevance to the overall themes of this blog from 2021 and 2022 —
Hedley Robinson (2021)— a PFD on section 136 procedure following on from assessment of a man who subsequently stabbed a victim. Touches upon information sharing, inter-agency communication and, I must presume, policy that surrounds those issues.
Anthony Fitzpatrick (2021) — a PFD about risk assessment in custody after it emerged that healthcare professionals in police custody did not assess risk objectively, in accordance with criteria in policy and training materials which related to risk assessment.
Anthony Preston (2021) — a PFD about a mental health incident in private premises, the police and ambulance service roles in assisting someone to hospital on a voluntary basis and subsequent roles in the police and NHS to mitigate risk.
Felicity Clough (2021)— a PFD about information sharing and vulnerability after use of the Mental Capacity Act 2005 to remove a vulnerable person to hospital. This relates to information sharing from one MH trust to another and from one police force to another, the incident having shown the staff in the trust and force were blind to information held by the trust and force where she lived.
Alexandra Tolley (2021) — a PFD about a detained MHA patient who left escorted leave is not an incident which, of itself, is of direct relevance because of what police officers did or did not do: but the background to her absence is noteworthy in terms of understanding assumptions about risk assessment prior to the granting of escorted leave under s17 MHA.
Trevor Smith (2021) — a PFD about information sharing between agencies and within departments of a police force. It was thought likely a mental health trust provided information about a patient’s overdose, prior to an armed operation to arrest him for domestic abuse allegations. This information was not passed to the SIO or the firearms officers involved in his arrest.
Jack Taylor (2022) — a PFD about responsibilities for MHA AWOL patients and powers under s18 MHA.
Joseph Martin (2022) — a PFD about information sharing between two police forces. One force had contact with a man who seemed vulnerable to some degree, but having contacted another force were not furnished with information known to that force about a psychotic relapse and which may have then justified use of s136 MHA.
Hannah Beardshaw (2022) — a PFD about threat to life / welfare checks after the police were asked to attend the address of someone believed to be suicidal. There was a delay in attending and assisting the ambulance service.
Daniel Clements (2022) – a PFD about extending the scope of s136 MHA after an incident where someone was detained and assessed as not having an acute mental illness and subsequently died.
Khalid Yousef (2022) — a PFD about liaison and diversion in custody, police assumptions about NHS staff expertise and the issue about escalating or reviewing matters which cause concern across agencies.
Jade Hutchings (2022) – a PFD about mental health training for police officers, including the inadequacy of purely online training and the fact that 2016 College of Policing training had not been completed in the police force concerned.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award

All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2022
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk