Zahra Mohamed

Dear Ms Bourke, I would like to start by expressing my sincere condolences to the family and friends of Ms Zahra Sharif Mohammed. 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 Ms Zahra Sharif Mohammed.

The Coroner’s MATTERS OF CONCERN are as follows: (1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks. (2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant. (3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024. (4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court. (5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant. (6) There is an ongoing risk that patients will harm themselves or others in the period 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 Ms Zahra Sharif Mohammed’s case:
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. 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. Whilst there is a maximum number of hearing slots within the online booking system for non- urgent cases, 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, 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. 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. HMCTS was not present in the Inquest proceedings, not being joined as an Interested Party, and so was given no opportunity to assist the Assistant Coroner’s inquiry. HMCTS does not accept the evidence presented that the timeline of 2 weeks for application to execution includes a delay at the magistrate court application stage of the process. 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. It follows therefore, that HMCTS asserts that ‘if an application had been submitted to the magistrates’ court that day (i.e. 4 October 2022)’, as an urgent application, that it is highly likely that the warrant would have been issued that day.
2) As above, had the case been considered urgent, established procedures exist. Guidance to practitioners describing the scheme for booking non-urgent, urgent and out of hours applications has 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.
3) HMCTS disputes the evidence presented to the Inquest that a 2-week timescale applied to obtaining a slot for a warrant hearing at the time in 2022 or up and until summer 2024. Had HMCTS been joined as a party we would have had the opportunity to provide rebuttal evidence and positively confirm the arrangements as described above for urgent warrants, if a non-urgent slot was not available in the time required.

4) As above, HMCTS has not been given the opportunity to provide our evidence on this point in the Inquest as an Interested Party. Our detailed internal review of service provision concludes our position, and we dispute the evidence presented about discouragement of applications to Highbury Corner magistrates’ courts. Our witnesses would have positively adduced evidence to the contrary.
5) As above, we found no evidence following our review to support the perceived position of delays in the issue of non-urgent or urgent warrants.
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 Ms Zahra Sharif Mohammed 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.