Ronald Bainborough

Dear Ms Bourke, I would like to start by expressing my sincere condolences to the family and friends of Mr Bainborough. On behalf of HMCTS, I write to provide our response to the matters of concern addressed to the Magistrates’ Courts in your Report to Prevent Future Deaths, dated 18th February 2025, following the inquest into the death of Mr Bainborough.

The Coroner’s MATTERS OF CONCERN are as follows: (1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed (2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest. (3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing. (4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled. (5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed. (6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.

HMCTS Response On behalf of HMCTS I offer our apologies for the delay in submitting this response to your report dated 18 February 2025. Following some unfortunate internal misdirection the report was only received in the correct part of the MOJ in June and we are grateful to have been allowed time to investigate before providing our response. Our initial investigation concerned our position in relation to the Inquest. Bearing in mind the content of the Prevention of Future Death reports which contain clear criticism of the service provision by London Magistrates’ Courts, we express our surprise that the MOJ (HMCTS) were not considered as falling within the status of Interested Parties to be joined by the Assistant Coroner under s.47 Coroner’s and Justice Act 2009. The results of our investigations below would indicate that we had potentially relevant evidence to give in relation to the operation of systems for considering s.135 Mental Health Act warrants. The Assistant Coroner has reached findings based on the witness evidence of other professional colleagues but without the evidence of HMCTS witnesses. Understandably, in these circumstances, we are now grateful for the opportunity to provide our insights on this sad case.

Responding to the relevant parts of the ‘matters of concern’ in Mr Bainborough’s case using the coroner’s numbering:
1) Listing is a judicial function and responsibility and arrangements for the operation of court lists are agreed with the judiciary and implemented by HMCTS. Arrangements for s.135 MHA warrants fall into these arrangements Our listing arrangements categorise mental health warrant applications as priority one work. It is acknowledged that this area of work carries the highest risks and vulnerabilities, therefore, it is prioritised in terms of the allocation of court time. Where necessary other work types will be adjourned off to prioritise the allocation of court time to deal with priority one work. Prior to the pandemic, a mental health practitioner who was applying for a mental health warrant could attend court and apply for the warrant. HMCTS operated (and still operates) an open-door policy for this category of priority one work. At the beginning of the pandemic there was a duty of care on HMCTS to protect court users and to embrace, wherever possible, remote ways of working. HMCTS swiftly responded and introduced a remote application system for mental health warrants, accompanied by an online booking system for applicants. The success of this system was such that once pandemic protection measures were removed applicants asked for the system to continue. The search warrant remote process was specifically designed to meet the needs and demands of the 32 London boroughs it serves. Since the inception of the remote process HMCTS has provided daily access to two separate, remote warrant sessions through Monday - Friday. The system is set up as online self service, which means applicants can select hearing dates and times for their applications. Where sessions have been booked in advance, it is not unusual and indeed is commonplace for applicants to cancel slots, those slots are released back to the booking in system. This business-as-usual model ensures that HMCTS, on average, provides more warrant slots, than the applications it receives daily. Alongside the self-service online booking process, HMCTS retained and retains an open-door policy which is widely known and

accepted practice and procedure. This process invites applicants to attend court, which provides immediate access to a court room, where the mental health warrant application will be listed. Applicants are encouraged to contact the centralised administration team who deal with such applications, in order that they can be directed to their local courthouse. However, should an applicant attend a local courthouse without contacting the centralised administration team, it remains the practice that the court will accommodate the applicant, given the nature and priority given to such applications. Additionally, the court provides a daily out of hours service for such applications, ensuring that the ability to apply for a mental health warrant is not hampered or impeded by a lack of access to the Judiciary. Again, there is an over provision of this service, to ensure that there are no delays in the out of hours operations.
2) Whilst there is a maximum number of hearing slots within the online booking system, the applicant’s access to a court hearing is not limited to the online booking slots. It is long established practice and procedure for mental health practitioners to attend court and apply for urgent mental health warrants. Additionally, HMCTS provides an out of hours service 7 days a week, where an applicant can access the Judiciary to apply for an urgent mental health warrant application. As a result of the various access routes to obtain an urgent mental health warrant, there is no need for an applicant to wait several days for a hearing. Evidence presented to the Inquest confirmed that the application was made on 18 August with an intended date for execution on 7 September 2023. On that basis, it clearly follows that this was not regarded as an urgent application. The warrant was considered and granted on 23 August, 3 standard working days following submission. There is no delay attributable in this case to the court listing process on a non- urgent submission. Had the application been considered and assessed as urgent, as above, emergency procedures are well established for applications to be made within the working week – and out of hours on a 24/7 basis. Noting the response provided by the Metropolitan Police, it is also clear that additional powers are available in case of emergency alongside the provisions of s135 MHA should these have been required.
3) As above, the application was considered 3 working days after submission. Had the case been considered urgent, established procedures existed. Guidance to practitioners describing the scheme for booking non-urgent, urgent and out of hours applications had been provided by HMCTS. Regular inter-agency meetings provide fora for discussion about service provision. No concerns about service provision have ever been raised with HMCTS by NHS colleagues. The warrant courts at Westminster and Uxbridge provide sufficient supply of hearings for non-urgent applications based on data analysis and reviews over time. All London magistrates’ courts are available at any time for urgent applications. A central team provides access to urgent applications on request. This service is used relatively frequently by AMHPs.
4) This matter does not apply to the magistrates’ courts responsibilities.
5) I interpret the reference to the absence of official fast track procedure as relating to the police element of the procedure, i.e. arrangements for execution of the warrant. I note that

the Metropolitan Police confirm in their response that they have no official fast track procedure for execution of warrants. This is not the case for applications for warrants to the magistrates’ court. Perhaps, on consideration of evidence in the absence of any from HMCTS, there has been a conflating of process here reaching a conclusion which is contrary to our researched and evidenced position.
6) Immediately on receipt of this report and in response to exchanges between HMCTS and NHS colleagues, we have re-iterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. A meeting to explore any concerns was arranged and held in July between senior HMCTS and NHS professionals. Continued communication of our arrangements will form part of our ongoing service and renewed commitment to partnership working to understand and resolve how serious misconceptions of service provision could have occurred amongst some AHMPs. We remain confident that our arrangements provide excellent access to AMHPs for urgent and emergency warrants.

Publication and reporting We take a neutral position on the Chief Coroner’s decision on the release and or publication of our response, save to point to the potential for any additional distress to be caused to the family of Mr Bainborough by the noted disagreement between HMCTS and NHS positions which were unable of being resolved during the Inquest process given our absence. We are content that the Chief Coroner will use diplomacy accordingly given the sensitivities to the family.

We thank you for the opportunity to provide these observations which are designed primarily to give assurance that our magistrates’ court arrangements are suitable for the urgent consideration of these important mental health warrant applications, necessarily prioritised under our joint arrangements with the judiciary in full recognition of the vulnerability and risks to patients and the public. We hope this contribution has been of assistance and confirm our standing commitment to working with colleagues to continually improve services.