“During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering…”
Dated 12 Aug 2024, from the coroner for Black Country. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 7 Oct 2024. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated12 Aug 2024
- Deadline7 Oct 2024
- Published on judiciary.uk30 Sep 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Midlands Police | Response publishedPublished on judiciary.uk in September 2024. |
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station. 2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time. 3. 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. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.
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, 2024-0516
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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