It’s 5am and I’ve been awake for a couple of hours, unable to get back to sleep … so I’ve put the coffee on and decided to start writing and this time it’s about “the system” we hear so much about. Last night I was reading a number of articles and the social media comments which accompanied them and one amongst them was Ian Acheson’s article this week in the Telegraph (£) about Nottingham and Southport.
It talks about “arrogant denial” adding, “every review has added up to a comprehensive audit of why nobody was responsible … this was not an unfortunate one-off, but yet another grotesque whole-system failure.”
I liked the article – it rings true for me having been inside that “system” but the problem I have with it, is we really don’t have a system at all – we have a coincidence of organisations with competing priorities, objectives and cultures which don’t work as one system, never have and in fairness, they were never designed to do so.
SYSTEMS THINKING
If we’re talking about systems, we may as well talk about systems thinking type approaches for the issues offered for consideration by VC in Nottingham or AR in Southport, you wouldn’t have the dysfunction thrown in unilaterally by one organisation, regardless of the impact on other parts of that system. You’d design out the inefficiencies by studying what actually happens to real people going through it. A lot of modern systems thinkers refers back to Taiichi Ohno who developed Toyota’s production system and whose success came from studying the system as a whole to eliminate waste, improve ‘flow’ and effect cultural changes within the organisation about how leaders manage and review.
I doubt there was any part of that where those responsible for engine design did it unilaterally from the reality of producing the chassis and bodywork – because the engine needs to fit the damned thing otherwise it doesn’t work and your car doesn’t move. When I hear people talking about Nottingham and how “the system failed” or similar, it makes me want to scream because it isn’t a system, it was never designed as a system and leaders in both policing and mental health are at liberty to inflict unilateral decisions upon each other and stand there saying “tough!”
And they do!
We know, for example, that the NHS mental health trust made it unilaterally clear to custody healthcare and the police, VC would not be admitted under a civil section of the Mental Health Act 1983 to a secure hospital. He should be charged and “picked up” under Part III – and they did this despite not knowing whether it was even possible he could be charged. Brilliant! – you might ask yourself what could possibly go wrong there (and if you want a clue, read about Alexander Lewis-Ranwell where similar thinking led to three murders)? There’s your equivalent of redesigning an engine without thought about whether it will still fit the chassis and bodywork – only with far graver consequences.
UNILATERAL ACTION
We know policing does this, too – when the police were contacted about AR in Southport they were effectively being asked by education services –
“There is a young man who hasn’t been seen for twelve months, he’s previously been under mental health services but that has been stopped because he won’t engage. We have attended his home address and his parents block access to him and at this stage, there no proof of life we can point to, because he simply hasn’t been seen. And if you check out his background, you’ll find there is problematic behaviour with knives and he’s been referred to the Prevent anti-terrorism mechanism three times. We are very concerned and only the police have legal powers to act urgently if he needs to be taken in to protective custody.”
So obviously the police said they wouldn’t attend, didn’t they? – the Right Care, Right Person flowchart said “we don’t do welfare checks in these circumstances” despite that unilaterally inflicting impotence on the system to check on safeguard or risk. The fact the police did not do the checks which would be necessary to know whether that decision was sound, or not, should be a concern to us all but Chief Constable’s will argue – and they have – RCRP is a necessary step to ensuring appropriate responses (not that it does) and that police resources can be focussed on “fighting crime and catching criminals”. These were the words of one Chief Constable about the police mission – not sure if he’s aware c80% of demand to his force is not about crime directly, but is often about the precursors of vulnerability and risk which could be preventative to crime.
PUSH / SHOVE
So they’re all at it – mental health trusts inflicting consequences on policing and criminal justice as well as vice versa, little evidence available that managers are very actively and in detail managing the gaps and risks and the overlaps between these two enormous paradigms of state intervention precisely because of the fact they have separate political objectives and governance. Even the so-called criminal justice “system” is not really a system – disparate organisations (policing, CPS, courts, prisons and probation) with distinct political governance via the Home Office or the Ministry of Justice, separate inspectorates and cultures.
It is like shooting fish in a barrel to look online for evidence of the five joint protocols which should exist in all areas to explain how the Mental Health Act 1983 should work and find them wanting or missing – and this has been the case for decades, despite Coroners flagging up the absence of poor quality of some of these things. It’s even possible to see Coroners issuing PFD notices for poor policies, requesting they be improved or replaced, only for them to issue a second PFD notice for the same inquest effectively tell those agencies off for not doing it – only for them still to fail to do it! In terms of accountability, our “system” doesn’t ensure someone is taken aside and asked why, after a tragic and potentially avoidable death, a police force and its statutory partners not one but twice disregarded PFD notices for a Coroner and why that senior officer of MH trust operations manager has allowed that to happen?
We do not have a “system” worth the name.
We have a collection of organisations who don’t truly talk to each other, who inflict unilateral damage on each other and which puts the organisation requirements ahead of the public service. If you are an AMHP, psychiatrist or mental health nurse who really does think you should decide against doing an MHA assessment because you’d prefer prosecution before you’ve even established with your police / CPS partners that prosecution is, in fact, possible, then I struggle for polite words. Its witless, its inane and its bloody dangerous.
NOTTINGHAM AND SOUTHPORT
The Nottingham and Southport public inquiries have revealed too many people in the organisations offering evidence do not have enough knowledge to be taking many of the calls they are – and I make this claim in the full knowledge that I was one of those people when I first became interested in why this interface between policing & mental health just doesn’t work well enough all of the time and drives risk in to the system. These two public inquiries are not going to tell us anything we didn’t already know from previous mental health homicide reviews or other inquests and inquiries.
Leaders on either “side” of this interface have failed to see themselves as just one part of a system which needs to be built as a whole, to work seamlessly across the risk-divide on the basis of shared information, shared responsibility and a shared understanding of how these organisations need to get over themselves and work together for all our safety and the saddest thing of all, as I continue on with my PhD, is the notion that these failures are actually deliberate.
Wilful ignorance – wilful intransigence – wilful indifference – everybody’s got someone else to blame and no-one’s in charge.
Awarded the President’s Medal, by
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, 2026
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
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