West Midlands Police
Police / Law Enforcement
Action Taken
West Midlands Police has implemented actions including the development of additional guidance for officers regarding mental health assessments, a review of risk assessment documentation, and ensuring access to Summary Care Records for healthcare providers in custody suites. They are working with mental health trusts to improve mental health service provision in custody. (AI summary)
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Dear Sir,
Prevention of Future Deaths report dated 12 August 2024, Parminder Singh Sanghera
I write in response to the Prevention of Future Deaths report dated the 12 August 2024 which followed on from the inquest touching upon the death of Mr Parminder Singh Sanghera. The report identified three key areas of concern to be addressed.
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.
This letter is the response on behalf of the Chief Constable of West Midlands Police (WMP). I am Chief Superintendent , Head of Criminal Justice Services at West Midlands Police. I hold responsibility for the custody portfolio. Health and Justice (previously Liaison and Diversion). Although, Health and Justice is an NHS commissioned service, located within WMP custody suites.
Health and Justice
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer
STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 27 September, 2024
2
Where a person is arrested for a Police and Criminal Evidence Act 1984 (PACE) matter and there are concerns that they are in mental health crisis, they will usually be referred to both a healthcare professional (‘HCP’) and Health and Justice, or Health and Justice alone, depending on the individual circumstances.
Pursuant to the above, Mr Sanghera was referred to an HCP to assess his fitness to be detained. The HCP noted that he was calm and compliant, making good eye contact and speaking in coherent sentences. He stated he had been hearing auditory voices for a few weeks but had no deliberate self-harm (DSH) or suicidal ideation at the time of the assessment. A plan was made for him to be referred to Liaison and Diversion the following morning (13 February
2023).
The role of Liaison and Diversion is to undertake screenings and assessments for a range of health and social care needs and other vulnerabilities in order to ensure those needs are being adequately addressed, to provide diversionary opportunities and ensure key decision makers within Criminal Justice Services (CJS) have sufficient understanding to make an informed decision.
Liaison and Diversion staff (Community Psychiatric Nurses) were engaged by the custody sergeant on the day of Mr Sanghera’s release. They decided, after screening him, not to attend and speak to him. This was due to the fact he had been assessed by mental health services on the 9 and 12 February 2023. No acute mental health concerns and/or self-harm/suicidal intent had been noted during these assessments. Mr Sanghera had been referred back to his GP with an update to be provided to his current care provider.
A decision was made by the investigation team that the offence Mr Sanghera was arrested for would be subject to No Further Action (NFA). Therefore, the power to legally detain Mr Sanghera in police custody under the provisions of PACE ceased. The criteria for continued detention to allow for a full assessment by an approved mental health professional and doctor under s136(2) of the Mental Health Act 1983 (MHA), namely that the person appears to be suffering from a mental disorder and in need of immediate care and control, was not met. In a custody setting, this assessment is made by a custody sergeant in consultation with a registered medical practitioner.
A pre-release risk assessment was conducted and Mr Sanghera was released from custody. The process followed by the staff involved in Mr Sanghera’s detention adhered to the requirements of PACE, Approved Professional Practice (APP) and the WMP Custody Standard Operating Procedure (SOP).
Where it is determined that a full mental health assessment is necessary pursuant to s136 MHA, it is normal practice for Health and Justice to coordinate this being conducted (during working hours). Outside of working hours this is coordinated by the custody healthcare provider, Mitie.
In the event that the PACE matter is finalised prior to this assessment being conducted, circumstances will be considered on a case by case basis but it is usual practice for the person
3
to be detained under s136 MHA. WMP officers are accustomed to applying the s136 criteria; as a force, we see particularly high volumes of s136 detentions within the custody environment.
Changes since 13 February 2023
Since the date of Mr Sanghera’s death, there have been a number of measures introduced within the custody environment aimed at continuously improving the level of care detained persons receive. These are not solely in response to the death of Mr Sanghera, but as part of the continuous improvement of the custody function service within WMP.
These improvements include:
(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training; (ii) Pre-release risk assessments are now subject to monthly audits to ensure quality; (iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response; (iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number. With the written consent of the detained person Mitie can then access further details covering current allergies; current acute and repeat medications; and discontinued medications. The system would not show why the detained person was on those medications. Sometimes a medical condition will be recorded for example epilepsy, asthma or diabetes. Mitie cannot access GP notes. Not everyone has Summary Care Records. For example, detained persons who are not UK residents or not registered with a GP. (v) WMP is working with the Birmingham and Solihull Mental Health Trust, providing them access to Perry Barr custody suite which will enable them to identify and fill any gaps in the provision of mental health services within the custody arena, and expand available service pathways from this setting; (vi) Under “Right Care, Right Person”, WMP is working closely with mental health partners, again with the ambition to bring mental health services into the custody environment. This will ensure access to the appropriate service at the earliest opportunity, and enable officers to determine, at each stage of a person’s detention, whether that person’s health needs or the investigation takes primacy.
The ultimate objective is to deliver a system wide response to those in mental health crisis.
4
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.
Prevention of Future Deaths report dated 12 August 2024, Parminder Singh Sanghera
I write in response to the Prevention of Future Deaths report dated the 12 August 2024 which followed on from the inquest touching upon the death of Mr Parminder Singh Sanghera. The report identified three key areas of concern to be addressed.
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.
This letter is the response on behalf of the Chief Constable of West Midlands Police (WMP). I am Chief Superintendent , Head of Criminal Justice Services at West Midlands Police. I hold responsibility for the custody portfolio. Health and Justice (previously Liaison and Diversion). Although, Health and Justice is an NHS commissioned service, located within WMP custody suites.
Health and Justice
Keeping our Communities Safe and Reassured
Working in partnership, making communities safer
STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES
Director of Legal Services
Your Ref:
Our Ref:
Email:
Date: 27 September, 2024
2
Where a person is arrested for a Police and Criminal Evidence Act 1984 (PACE) matter and there are concerns that they are in mental health crisis, they will usually be referred to both a healthcare professional (‘HCP’) and Health and Justice, or Health and Justice alone, depending on the individual circumstances.
Pursuant to the above, Mr Sanghera was referred to an HCP to assess his fitness to be detained. The HCP noted that he was calm and compliant, making good eye contact and speaking in coherent sentences. He stated he had been hearing auditory voices for a few weeks but had no deliberate self-harm (DSH) or suicidal ideation at the time of the assessment. A plan was made for him to be referred to Liaison and Diversion the following morning (13 February
2023).
The role of Liaison and Diversion is to undertake screenings and assessments for a range of health and social care needs and other vulnerabilities in order to ensure those needs are being adequately addressed, to provide diversionary opportunities and ensure key decision makers within Criminal Justice Services (CJS) have sufficient understanding to make an informed decision.
Liaison and Diversion staff (Community Psychiatric Nurses) were engaged by the custody sergeant on the day of Mr Sanghera’s release. They decided, after screening him, not to attend and speak to him. This was due to the fact he had been assessed by mental health services on the 9 and 12 February 2023. No acute mental health concerns and/or self-harm/suicidal intent had been noted during these assessments. Mr Sanghera had been referred back to his GP with an update to be provided to his current care provider.
A decision was made by the investigation team that the offence Mr Sanghera was arrested for would be subject to No Further Action (NFA). Therefore, the power to legally detain Mr Sanghera in police custody under the provisions of PACE ceased. The criteria for continued detention to allow for a full assessment by an approved mental health professional and doctor under s136(2) of the Mental Health Act 1983 (MHA), namely that the person appears to be suffering from a mental disorder and in need of immediate care and control, was not met. In a custody setting, this assessment is made by a custody sergeant in consultation with a registered medical practitioner.
A pre-release risk assessment was conducted and Mr Sanghera was released from custody. The process followed by the staff involved in Mr Sanghera’s detention adhered to the requirements of PACE, Approved Professional Practice (APP) and the WMP Custody Standard Operating Procedure (SOP).
Where it is determined that a full mental health assessment is necessary pursuant to s136 MHA, it is normal practice for Health and Justice to coordinate this being conducted (during working hours). Outside of working hours this is coordinated by the custody healthcare provider, Mitie.
In the event that the PACE matter is finalised prior to this assessment being conducted, circumstances will be considered on a case by case basis but it is usual practice for the person
3
to be detained under s136 MHA. WMP officers are accustomed to applying the s136 criteria; as a force, we see particularly high volumes of s136 detentions within the custody environment.
Changes since 13 February 2023
Since the date of Mr Sanghera’s death, there have been a number of measures introduced within the custody environment aimed at continuously improving the level of care detained persons receive. These are not solely in response to the death of Mr Sanghera, but as part of the continuous improvement of the custody function service within WMP.
These improvements include:
(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training; (ii) Pre-release risk assessments are now subject to monthly audits to ensure quality; (iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response; (iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number. With the written consent of the detained person Mitie can then access further details covering current allergies; current acute and repeat medications; and discontinued medications. The system would not show why the detained person was on those medications. Sometimes a medical condition will be recorded for example epilepsy, asthma or diabetes. Mitie cannot access GP notes. Not everyone has Summary Care Records. For example, detained persons who are not UK residents or not registered with a GP. (v) WMP is working with the Birmingham and Solihull Mental Health Trust, providing them access to Perry Barr custody suite which will enable them to identify and fill any gaps in the provision of mental health services within the custody arena, and expand available service pathways from this setting; (vi) Under “Right Care, Right Person”, WMP is working closely with mental health partners, again with the ambition to bring mental health services into the custody environment. This will ensure access to the appropriate service at the earliest opportunity, and enable officers to determine, at each stage of a person’s detention, whether that person’s health needs or the investigation takes primacy.
The ultimate objective is to deliver a system wide response to those in mental health crisis.
4
If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.