The death of Mr Parminder Sanghera in February 2023 was a very sad event. A coroner’s jury has found he died by drowning in the canal adjacent to the Oldbury police custody block in the West Midlands area shortly after his release from there. I was the duty inspector for the area when Mr Sanghera’s body was found and attended the scene immediately.
His Majesty’s Coroner for the Black Country has issued a Preventing Future Deaths report to the Chief Constable of West Midlands Police and to the Midlands Partnership Trust (who operate custody’s liaison and diversion services) about arrangements in police custody for assessment of those of experience mental health crisis.
It’s a little difficult to see what HM Coroner is getting at in this case. Let me outline the timeline of events.
WOLVERHAMPTON
- Mr Sanghera was arrested in Wolverhampton – calls to the police around 1723hrs on 12th February 2023 reported a naked man running around in the city.
- He was located and arrested for outraging public decency.
- He had a head injury and was displaying behaviour that concerned officers about his mental health so was taken to New Cross Hospital.
- Arriving at 1826hrs, he was seen and discharged from there at 2347hrs after being treated.
- Mr Sanghera was taken to the police custody suite in Oldbury where his detention authorised at 0034hrs on 13th February.
- He was kept in custody overnight on enhanced levels of observations and seen by a Health Care Professional (HCP).
- A decision was made in the early afternoon to release Mr Sanghera without charge , and a pre-release risk assessment completed at 1.51pm which found no concerns about risk of suicide or self-harm following release.
- The custody record further stated Mr Sanghera was suffering from behavioural issues and that he had been reviewed by L&D when assessed for mental health issues the day before.
- He was not found to warrant a full Mental Health Act assessment the previous day.
Mr Sanghera was reported to be unwilling to leave custody and force was used to escort him from the cell and the custody suite as a whole by two police staff. The making of transport arrangements were not deemed necessary and it was stated that he was not showing signs of mental vulnerability. External CCTV footage showed Mr Sanghera left custody at around 1.55pm and stood outside for a while. He then walked away and returned to the custody car park area numerous times. He was last seen on CCTV outside the custody suite at 1552hrs walking towards the adjacent canal towpath.
At 1700hrs, a log was created reporting someone thought a body was floating in the canal. He was pronounced dead around 1800hrs at the location.
MENTAL HEALTH ACT ASSESSMENT
Mr Sanghera was seen an examined by NHS medical staff twice – firstly at New Cross Hospital and secondly at the police custody suite where L&D services operated by the NHS are based. It’s one of those very tricky issues and we’ve seen PFDs from Coroners about West Midlands L&D services before.
On the one hand, healthcare professionals are better placed to make clinical judgements about the necessity of a Mental Health Act assessment but on the other hand we know those judgements are fallible. Remember: Valdo Calocane was assessed under the Mental Health Act twice within a few hours in May 2020: not “sectionable” the first time, swift “sectioned” the second – within just hours.
What is a little regrettable in this case, is the PFD stating “evidence at this inquest heard he was suffering a mental health crisis at the time.” It’s regrettable because it’s not explicit about whether the description given in the PFD of behaviour at arrest, at hospital and in custody is the basis for “mental health crisis at the time” or whether the inquest heard other, new information which was not know to the NHS and police professionals responding to him.
BIZARRE THINGS
What struck me about this case was the fact a man could be running around a city centre naked, head injured and in obvious distress and we don’t see him assessed under the Mental Health Act. The PFD notice says “he was deemed to be suffering from behavioural issues rather than a mental health crisis”.
Behavioural issues – I’m not sure I even know what that means.
I obviously understand the words, but it’s a phrase we sometimes hear from mental health professionals: “it’s not mental health – it’s behavioural”. It doesn’t really mean anything. I know a number of mental health professionals – psychiatrists as well as nurses and AMHPs – who just groan when they hear it said, before going off on one about “poor care” and using the phrase as an excuse not to support people who need it. Now equally, I’m sure those who employ the term are using it for a reason they feel justified: an umbrella term for bizarre behaviour they feel is not due to mental illness but all of this just opens the debate I don’t get in to about how psychiatric and psychological services classify, group and describe human behaviours. Way above my pay grade …
My own concern is that given very obvious erratic behaviour displayed in an overlap with criminal conduct and his obvious vulnerability, police custody was probably not the place for definitive determinations about how this poor guy came to police attention and the nature of the background to it. HM Coroner for the Black Country summed it up in the PFD notice –
“My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full Mental Health Act assessment to take place before release.”
Part of my ongoing concerns about Liaison and Diversion services and I repeat the point: not the first time HM Coroners have raised concerns and not the first time in this force’s area.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
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
Mental Health Cop 