“Confusion over applicable local policy and working standards for dealing with s.136…”

The coroner’s concerns

Confusion over applicable local policy and working standards for dealing with s.136 detention I am concerned that there is a lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention. At the outset of this investigation, a direction was given for disclosure of “Local memoranda or policies concerning how EMAS and Notts police jointly manage health incidents”. In response to that direction, a number of policies were disclosed, including a document entitled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedures”. Various versions of this policy were disclosed to the coroner, including a 2018, 2021 and 2024 version. During the course of the inquest so far, I heard evidence from both the police and the ambulance service in relation to the local policy for managing s.136 incidents. The police and the ambulance service do not share an understanding of which policy they are expected to adhere to and whether there is a joint local policy. The police consider that the document above (as amended) is the applicable framework, whilst EMAS are currently unable to tell me if this policy has agreed to by them, notwithstanding that they appear as one of the agencies that formed part of the working group for each version of the MOU. The witness who gave policy evidence on behalf of EMAS told me that they only work to their own internal local standard, which is different to that in the MOU. Regulation 28 – After Inquest Document Template Updated 30/07/2020 Persons detained under s.136 of the Mental Health Act 1983 are some of the most vulnerable in society. Their liberty has been removed, and they are reliant upon state agencies to protect their right to life. I am extremely concerned that there is no joined up thinking, or understanding, between the police and the ambulance service as to which policy and which working standards apply when furthering the protection of that right. I am concerned that this lack of basic understanding of policy and working standards by emergency services, if it persists, poses a risk of preventable future deaths.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0363

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0