So far, it seems most of the things which could go wrong in Nottingham, did go wrong but we’re yet to see the public inquiry final report, which is due next spring. We heard evidence on policing and mental health as well from the CPS and mental health services, including the expert psychiatric witnesses who provided reports and opinions to the criminal courts. It was fascinating to watch, as we rarely have the opportunity to see psychiatrists examined by barristers about the clinical opinions they offer a criminal court and we know there are already some obvious questions to raise.
These horrible events in Nottingham in June 2023 were building for years – seemingly a product of a thousand different small or not-so-small errors and omissions; or of mistakes and over-simplifications made; or partnerships which failed to develop plans for effective joint responses to various predictable situations and where they failed to ensure proper communication in a shared language, with a shared ambition to take these two massive paradigms of state intervention and coercion and ensure the gaps and the overlaps were managed.
Nottingham was the result of many years of failed leadership in both policing and mental health. Whilst I suspect this kind of thing would be far less likely in some police force areas than others, I do suspect it could happen in most of them. Even worse, I’m afraid, I believe the likelihood of another set of circumstances coming together where a thousand small things have gone awry to create the conditions in which another ‘Nottingham’ could happen are actually greater now than they were in 2023.
WILFUL IGNORANCE
What follows here is me thinking out loud about the underpinning ideas which are emerging in my PhD and reflecting on some changes since June ’23, both of which sit behind the kind of analysis I will be doing later this year on the PFD notices I’ve gathered, RCRP-related and not.
- Firstly, it’s obvious when you listen to the evidence of former Chief Constable Kate Meynell, Deputy Chief Constable Rob Griffin and other senior officers including the SIO for the homicide investigation, most of them don’t have a very nuanced or insightful view in to mental health as a topic within policing, including how it impacts criminal investigation.
- Secondly, it’s obvious officers at all ranks have sub-contracted a lot of their legal thinking and decision-making to doctors and nurses in the very mistaken belief doctors are “experts”. Experts on psychiatry or mental health nursing, perhaps – but not experts on the interface of criminal law and mental health where serious crime investigations are running and I’m sure we are going to see that exposed in next year’s report. In case anyone in those professions is offended by that take, it’s a view expressed in the courts as well.
- Thirdly, it’s obvious from an online search of policies and protocols as well as from surveying PFD notices which have been issued in recent years for mental health police contact deaths (MH-PCDs) in Nottinghamshire, these organisations are very obviously not properly talking to each other and have made a number of basic mistakes in other MH-PCDs. In just one example, the police and ambulance service agreed a protocol on s136 and then failed to ensure all frontline staff knew about it before insisting RCRP would fix things when it was nothing to do with the incident at all.
- Finally, it’s obvious officers in Nottinghamshire at all levels simply have not been trained – obviously I have a professional history which gave me insight to a lot of that and for years I’ve deliberately chosen not to write about an experience I had with Nottinghamshire Police about training whilst I was at the College of Policing, because they really don’t come out of it well. My best guess now is, if I told them the story, they’d have no idea what I was on about as I suspect it will have disappeared from their organisational memory as the people involved have moved on or, more likely, retired.
Mental health police contact deaths rarely have one or two straight-forward causal explanations it’s almost always multi-factorial where a collision of circumstances comes together and then almost everybody tries to highlight the failings of others, often whilst denying or minimising their contribution to the outcome. We’ve seen this in the Inquiry when Rob Griffin repeated his fallacious opinion that execution of the outstanding arrest warrant would likely have made no difference. We’ve seen it in other inquests, like David Stacey (Leicestershire, 2017) and Nigel Abbott (West Midlands, 2019), to name just two others.
MENTAL HEALTH SERVICES
And we need to think about mental health services, not least because some of the very high-profile police contact deaths, which are now spoken of purely as police related, “more than minimally” involved mental health services, including neglect by them. We need to do this by remembering the failures in mental health and policing Nottingham, VC is by no means the worst example of an offender-patient whose risk is not being managed – I made this point well over twenty-years ago after my MSc dissertation on this topic and yet here we are.
The Mental Health Act 2025 amends our current laws and various aspects of it should be causing us to wonder about the furtherance and expansion of so-called community care and the ever-greater structural / organisational level risk it builds.
To give just one example for now –
- A legal change to the discharge of patients who were hospitalised after going through the criminal justice system where they were flagged as posing “a risk of serious harm to the public” has already taken effect in February 2026.
- Forensic patients can now be discharged from hospital in a wider range of circumstances, something known as “supervised discharge” under s42(1A) where they are subject to a deprivation of their liberty in the community to ensure they are supervised more closely than ‘normal’ conditionally discharged patients.
Government guidance on supervised discharge is that where it starts to fail and a patient moves beyond the supervision required by leaving their accommodation, they should call the police. The government’s “Supervised Discharge FAQs” contains the following question and answer –
Q23. What can be done if a patient is planning to leave their accommodation without supervision?
A23. Accommodation staff should be aware that if a patient decides to leave the accommodation the usual procedures of alerting the Police and following the processes set out in the patient’s care plan must be undertaken. Accommodation staff should make the patient aware that they are likely to be recalled to hospital if they choose to leave. Staff must also contact the community team as soon as possible who will discuss recall with MHCS. If a recall has been authorised the patient is immediately liable to be returned to hospital.
RECOGNITION OR ASSESSMENT OF RISK
It will be really interesting to see what the RCRP world makes of all this, not least because it’s fair to point out that alerting the police to a supervised discharge patient leaving accommodation without an escort affords the police absolutely no legal powers whatsoever. The legal reform which introduces this new type of community care for forensic patients – something described in the guidance as a “sub-set of conditional discharge” – leaves the recall mechanism untouched.
In order to recall a supervised discharge or conditionally discharged patient to hospital, authority needs to be given and a warrant issued by the Secretary of State for Justice under s42(4) MHA. Then and only then, will the police have a legal authority to return the patient to hospital.
It’s fair to accept that if the police were called, bearing in mind a supervised discharge patient is someone previously labelled by a criminal court as posing a “serious risk of harm to the public”, the police could locate and detain them under s136 MHA, if found in a location where that power can be used. But then you hit up against the potential that call handlers being told “A supervised discharge patient has left their accommodation without an escort” will not necessarily know what supervised discharge means, in law and that it could relate to someone who poses very significant risks.
NOTTINGHAM
We began by discussing Nottingham – I fear the various reforms we are seeing unfold and the policy changes by imposed by the police on our mental health system through RCRP, will combine to make the tragic outcomes of 2023 more likely, not less. We already know some misguided ideas were bouncing around in 2020 about whether or not to “section” VC, predicated on concerns about race disproportionality in MHA admissions – something talked about for years but dismissed by Professor Swaran Singh (£) who has worked on this all his professional life.
If you want to evolve the system so fewer people are admitted and more patients in the forensic system are discharged, including in circumstances where they cannot necessarily be immediately re-detained by the police until a warrant is issued, and you’re playing with new mental health law like amendments to community treatment orders which were of questionable utility anyway and where the new changes are not yet tried and tested, you might wonder if I’m right about the structural level management of risk.
And that’s before you factor in all the things which can go wrong because of individual’s professional decision making. The CQC reports on the mental health care of VC already questioned, for example, whether he should have been admitted on occasion under s3 not s2, the difference being he could have then been discharged from hospital on a CTO which makes any disengagement more noticeable whilst offering an bureacraticaly more straight-forward way of returning him to hospital.
Whatever comes in the future: we need more professionals across all these bodies with greater legal literacy about the old as well as the new laws. This is all about the beginning of risk at the end of law but that doesn’t mean we don’t need basic legal knowledge which has only been on display at the public inquiry from the barristers involved.
We’re busy building another Nottingham – and let’s not pretend it isn’t obvious, despite the wilful blindness.
NB: this is the latest in post about the terrible events in Nottingham, June 2023. You can find all the others collated on a specific Nottingham resources page along with other materials, inc reports and legal documents.
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
Mental Health Cop 