“This PFD should be read in conjunction with the PFD that I issued mid-inquest, dated 17…”

The coroner’s concerns

This PFD should be read in conjunction with the PFD that I issued mid-inquest, dated 17 July 2025. 1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommended that: A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research. This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services. Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’. Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic. I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place. I have also heard that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD. That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue. 2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over the apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance. Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows: The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception. EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards. Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows: There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them. Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention. My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that the is compliance with this guidance, published by the Department of Health. The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983. 3. Police use of an ambulance as the mode of conveyance for s.136 detainees I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes). I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions). Of the nine police officers that gave evidence to me in this inquest on s.136 ma

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

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judiciary.uk, Prevention of Future Deaths reports, 2025-0383

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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