Khalid Yousef

Dear Mr Bennett

Re: Regulation 28 Report to Prevent Future Deaths – Khalid Seneen Yousef who died on 4 January 2018

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 June 2022 concerning the death of Khalid Seneen Yousef on 4 January 2018. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Yousef’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised following Mr Yousef’s death have been listened to and reflected upon. I would also like to sincerely apologise for the delay in responding to your Report.

Following the inquest, you raised a number of concerns in relation to the Liaison and Diversion (L&D) police custody suite model, which is a nationally commissioned service, and access to psychiatrists. With input from the NHS England West Midlands regional Health and Justice team, I have responded to each of your specific concerns in turn below:

1. The L&D police custody suite model has not commissioned psychiatrists.

In terms of the commissioned health services that operate within police custody suites, there are two services as follows:
• A police custody healthcare service (PCHS). PCHS is commissioned by the Police & Crime Commissioner (PCC) for each force. The National Police Chiefs’ Council (NPCC) issue a national service specification for this service, although this takes the form of guidance for PCC’s rather than being mandatory. The PCHS is responsible, inter alia, for advising the police on fitness to detain, fitness to interview and fitness to charge (in accordance with the provisions of the Police & Criminal Evidence Act 1984).
• Liaison and diversion service (L&D). This service is commissioned by NHS England, via regional Health & Justice teams, in accordance with a published national service specification which can be found at

service-specification/. The L&D service seeks to identify and assess individuals National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26 October 2022

with vulnerabilities, make supported referrals to appropriate services and, with the individual’s consent, share relevant information with key decision makers within criminal justice agencies.

The NPCC national service specification (Annex 1) specifically includes responsibility for responding to individuals in mental health crisis, including placing a requirement on the provider to facilitate assessments under the Mental Health Act. The NHS England L&D national service specification, by design, specifically excludes these functions.

The inclusion of psychiatric provision within the makeup of L&D multi-disciplinary teams is not presently considered necessary. If and when an L&D practitioner identifies secondary mental health needs, that do not require immediate intervention, a supported referral is made to the appropriate local community mental health service. The PCHS operates within police custody suites 24 hours a day, whereas L&D services are generally present for 12 hours a day. In the event of a Mental Health Act assessment being required, this would be facilitated by the provider through the PCHS rather than L&D. As stated below, the two services work closely and their specifications make clear who has responsibility for responding to those in mental health crisis.

In summary, it is not the responsibility for L&D services to respond to those in mental health crisis, that function falls to PCHC services. Where an L&D practitioner has concerns regarding an individual’s mental health, that falls short of requiring an immediate crisis response, the expectation is that they will liaise with that individuals community mental health team for further advice (which may involve speaking with a psychiatrist or psychologist) and if the person has disengaged will provide a supported referral back into that service.

2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.

The PCHS and L&D national service specifications are written to complement each other, and to make clear which service is responsible for responding to those in mental health crisis. NHS England’s national Health & Justice team officials work closely with their counterparts at the NPCC to ensure that the two specifications remain aligned.

NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.

3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.

A copy of the response from BSMHFT has been shared with NHS England, the response of the Chief Constable has not been shared.

I understand from the NHS England West Midlands regional Health & Justice team that this matter has been raised at the force’s Joint Strategic Operational Group. This is a governance meeting where the police meet with health and wider partners, to provide clarity as to the responsibility of services to respond to those in mental health crisis, and to ensure that appropriate messages are regularly disseminated both to police and health audiences.

4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

I am assured that NHS England’s regional Health & Justice commissioning team are addressing this matter directly with the BSMHFT through regular contract review meetings.

BSMHFT responded as follows to the issues raised: “The Trust takes these issues very seriously. The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary” The Regional Commissioner will further discuss this case and progress on the above actions at the next scheduled contract meeting (October 2022). The outcome of that meeting will be included in the November 2022 Quality Report and presented to the Health and Justice Assurance and Improvement Group, where next steps will be agreed.

NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.

NHS England regional Health & Justice commissioners will have regard to the framework when addressing workforce and quality issues with providers.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical

Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the tragic death of Mr Yousef, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.

Once again, thank you for bringing these important concerns and issues to my attention. I hope my response reassures you that appropriate services and measures are in place to ensure the safety and wellbeing of those individuals with specific mental health vulnerabilities, but that further action is being taken to review and improve certain aspects of these services.

Please do not hesitate to contact me should you need any further information.

Dear Mr Bennett

Re: Regulation 28 Report to Prevent Future Deaths – Khalid Seneen Yousef who died on 4 January 2018

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 June 2022 concerning the death of Khalid Seneen Yousef on 4 January 2018. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Yousef’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised following Mr Yousef’s death have been listened to and reflected upon. I would also like to sincerely apologise for the delay in responding to your Report.

Following the inquest, you raised a number of concerns in relation to the Liaison and Diversion (L&D) police custody suite model, which is a nationally commissioned service, and access to psychiatrists. With input from the NHS England West Midlands regional Health and Justice team, I have responded to each of your specific concerns in turn below:

1. The L&D police custody suite model has not commissioned psychiatrists.

In terms of the commissioned health services that operate within police custody suites, there are two services as follows:
• A police custody healthcare service (PCHS). PCHS is commissioned by the Police & Crime Commissioner (PCC) for each force. The National Police Chiefs’ Council (NPCC) issue a national service specification for this service, although this takes the form of guidance for PCC’s rather than being mandatory. The PCHS is responsible, inter alia, for advising the police on fitness to detain, fitness to interview and fitness to charge (in accordance with the provisions of the Police & Criminal Evidence Act 1984).
• Liaison and diversion service (L&D). This service is commissioned by NHS England, via regional Health & Justice teams, in accordance with a published national service specification which can be found at

service-specification/. The L&D service seeks to identify and assess individuals National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26 October 2022

with vulnerabilities, make supported referrals to appropriate services and, with the individual’s consent, share relevant information with key decision makers within criminal justice agencies.

The NPCC national service specification (Annex 1) specifically includes responsibility for responding to individuals in mental health crisis, including placing a requirement on the provider to facilitate assessments under the Mental Health Act. The NHS England L&D national service specification, by design, specifically excludes these functions.

The inclusion of psychiatric provision within the makeup of L&D multi-disciplinary teams is not presently considered necessary. If and when an L&D practitioner identifies secondary mental health needs, that do not require immediate intervention, a supported referral is made to the appropriate local community mental health service. The PCHS operates within police custody suites 24 hours a day, whereas L&D services are generally present for 12 hours a day. In the event of a Mental Health Act assessment being required, this would be facilitated by the provider through the PCHS rather than L&D. As stated below, the two services work closely and their specifications make clear who has responsibility for responding to those in mental health crisis.

In summary, it is not the responsibility for L&D services to respond to those in mental health crisis, that function falls to PCHC services. Where an L&D practitioner has concerns regarding an individual’s mental health, that falls short of requiring an immediate crisis response, the expectation is that they will liaise with that individuals community mental health team for further advice (which may involve speaking with a psychiatrist or psychologist) and if the person has disengaged will provide a supported referral back into that service.

2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.

The PCHS and L&D national service specifications are written to complement each other, and to make clear which service is responsible for responding to those in mental health crisis. NHS England’s national Health & Justice team officials work closely with their counterparts at the NPCC to ensure that the two specifications remain aligned.

NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.

3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.

A copy of the response from BSMHFT has been shared with NHS England, the response of the Chief Constable has not been shared.

I understand from the NHS England West Midlands regional Health & Justice team that this matter has been raised at the force’s Joint Strategic Operational Group. This is a governance meeting where the police meet with health and wider partners, to provide clarity as to the responsibility of services to respond to those in mental health crisis, and to ensure that appropriate messages are regularly disseminated both to police and health audiences.

4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

I am assured that NHS England’s regional Health & Justice commissioning team are addressing this matter directly with the BSMHFT through regular contract review meetings.

BSMHFT responded as follows to the issues raised: “The Trust takes these issues very seriously. The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary” The Regional Commissioner will further discuss this case and progress on the above actions at the next scheduled contract meeting (October 2022). The outcome of that meeting will be included in the November 2022 Quality Report and presented to the Health and Justice Assurance and Improvement Group, where next steps will be agreed.

NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.

NHS England regional Health & Justice commissioners will have regard to the framework when addressing workforce and quality issues with providers.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical

Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the tragic death of Mr Yousef, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.

Once again, thank you for bringing these important concerns and issues to my attention. I hope my response reassures you that appropriate services and measures are in place to ensure the safety and wellbeing of those individuals with specific mental health vulnerabilities, but that further action is being taken to review and improve certain aspects of these services.

Please do not hesitate to contact me should you need any further information.

Dear Mr Bennett,

Re: Prevention of Future Deaths in the inquest of Khalid Yousef (deceased)

Thank you for sharing the Prevention of Future Death’s report with us on 23 June 2022. We would like to assure you that the Trust takes your concerns very seriously. The incident which led to the inquest was a tragic set of circumstances and the Trust has taken action to respond to the concerns you have raised within your report. I intend to respond to each of the points in turn.

1. The L&D police custody suite model has not commissioned psychiatrists.

The Birmingham and Solihull Mental Health NHS Foundation Trust gave evidence in court during the inquest that the Liaison and Diversion Service follow the national model. The Trust is therefore unable to respond to the point around commissioning of psychiatrists within the model. We note that NHS England was also sent a copy of the Prevention of Future Deaths Report and we hope that they will be able to provide more information to you in due course.

2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.

The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.

Customer Relations │ Mon – Fri, 8am – 6pm Tel: 0800 953 0045 │ Text: 07985 883 509

Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk

Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB

3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.

As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.

4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

The Trust takes these issues very seriously. Up until the point of the inquest hearing the Trust was not made aware of any concerns around experience, training or supervision for Ms Fitzgerald. On hearing the issues raised during the inquest, the Head of Patient Safety met with the Team Manager to raise these matters for reflection and to ascertain if any improvements are required. This would be part of our usual process for reflective practice within the Trust.

The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.

Please be assured that the Trust will continue to make any necessary changes or improvements to ensure patient safety and learn lessons from incidents in the future.

Dear Mr Bennett,

Re: Prevention of Future Deaths in the inquest of Khalid Yousef (deceased)

Thank you for sharing the Prevention of Future Death’s report with us on 23 June 2022. We would like to assure you that the Trust takes your concerns very seriously. The incident which led to the inquest was a tragic set of circumstances and the Trust has taken action to respond to the concerns you have raised within your report. I intend to respond to each of the points in turn.

1. The L&D police custody suite model has not commissioned psychiatrists.

The Birmingham and Solihull Mental Health NHS Foundation Trust gave evidence in court during the inquest that the Liaison and Diversion Service follow the national model. The Trust is therefore unable to respond to the point around commissioning of psychiatrists within the model. We note that NHS England was also sent a copy of the Prevention of Future Deaths Report and we hope that they will be able to provide more information to you in due course.

2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.

The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.

Customer Relations │ Mon – Fri, 8am – 6pm Tel: 0800 953 0045 │ Text: 07985 883 509

Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk

Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB

3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.

As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.

4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

The Trust takes these issues very seriously. Up until the point of the inquest hearing the Trust was not made aware of any concerns around experience, training or supervision for

On hearing the issues raised during the inquest, the Head of Patient Safety met with the Team Manager to raise these matters for reflection and to ascertain if any improvements are required. This would be part of our usual process for reflective practice within the Trust.

The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.

Please be assured that the Trust will continue to make any necessary changes or improvements to ensure patient safety and learn lessons from incidents in the future.

Dear Mr Bennett

West Midlands Police response to HM Coroner’s Regulation 28 report to prevent future deaths

This is the response of the Chief Constable of West Midlands Police to the Regulation 28 report issued by Her Majesty’s Area Coroner for Birmingham and Solihull on 23 June 2022 following the conclusion of the inquest into the death of Khalid Seneed Yousef.

While the Coroner did not identify any specific failings by West Midlands Police (WMP) in his conclusions, in responding to the Regulation 28 report, I necessarily confine myself to the specific points of concern raised and no attempt is made to revisit wider issues considered during the inquest. HM Area Coroner’s four specific concerns, set out in Part 5 of the report, are as follows:

1. The Liaison and Diversion (L&D) police custody suite model has not commissioned psychiatrists.
2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.
3. West Midlands Police officers and Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) staff do not sufficiently understand the role and limitations of the L&D police custody suite model.
4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

Upon careful reflection, I consider that the second and third concerns are pertinent to WMP, whereas the first and fourth concerns are of relevance to other addressees of the Regulation 28 report, namely: (i) Chief Executive NHS England; (ii) Chief Executive Birmingham and Solihull Mental Health Trust and/or (iii) The Rt Hon Priti Patel MP, Home Secretary.

In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.

However, I understand that the Chief Executive of BSMHT will be addressing both of these issues in her response.

For these reasons, this response focuses on the second and third concerns identified by HM Area Coroner for Birmingham and Solihull. In order to ensure that the second and third concerns are comprehensively addressed and bearing in mind “the ‘gap’ in commissioning” identified in the Regulation 28 report, WMP has engaged with BSMHT prior to preparing this response.

In relation to the second concern, the mental and physical wellbeing of detainees is a matter for which the Chief Constable is ultimately responsible. This is a matter upon which both WMP and BSMHT are clear. However, it is important to note that this responsibility does not necessarily entail the direct recruitment of medical or mental health clinicians. As is common in custody provision across England, there is an expectation that locally commissioned health provision will be available to detainees in the same way that it would for members of the public who are not in detention. While it is my responsibility to maintain the welfare of detainees, this responsibility is discharged by establishing adequate processes and delivering appropriate training and direction to custody officers/staff about when and how to access clinical support.

Turning to the third concern, following the evidence adduced at the inquest, it is acknowledged that the understanding of some WMP custody officers/staff in relation to the role and limitation of L&D requires improvement. Given that custody officers/staff are not medically trained, it is reasonable for them to be able to rely on, and defer to, the professional opinion of healthcare practitioners in relation to matters of mental and physical health. At the same time, it is accepted that custody officers/staff need to understand the differing levels of expertise of various clinicians and healthcare practitioners. It is also clear from the inquest that custody officers/staff need to understand that even in circumstances where an assessment is made by a suitably qualified clinician at a specific point in time, they should always feel able to question and request a review of that decision if and when further information becomes available.

For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:

• The creation of a formal escalation process for when custody staff/officers believe that an L&D decision is wrong. This escalation process will ensure custody officers/staff dealing with such situations make better use of the Mental Health Tactical Advisors who have access to a detained person’s mental health history through partners, and have a better degree of knowledge/understanding of these issues and may therefore be better placed to review the L&D decision;
• A review of the training provided to custody officers/staff specifically in relation to mental health issues;
• Provision of clear and unequivocal advice to all front-line staff as to the nature, scope and limitations of the current L&D function.

I hope that this response reassures HM Area Coroner for Birmingham and Solihull that the matters of concern that have been raised in the Regulation 28 report are being addressed.

Dear Mr Bennett

West Midlands Police response to HM Coroner’s Regulation 28 report to prevent future deaths

This is the response of the Chief Constable of West Midlands Police to the Regulation 28 report issued by Her Majesty’s Area Coroner for Birmingham and Solihull on 23 June 2022 following the conclusion of the inquest into the death of Khalid Seneed Yousef.

While the Coroner did not identify any specific failings by West Midlands Police (WMP) in his conclusions, in responding to the Regulation 28 report, I necessarily confine myself to the specific points of concern raised and no attempt is made to revisit wider issues considered during the inquest. HM Area Coroner’s four specific concerns, set out in Part 5 of the report, are as follows:

1. The Liaison and Diversion (L&D) police custody suite model has not commissioned psychiatrists.
2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody.
3. West Midlands Police officers and Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) staff do not sufficiently understand the role and limitations of the L&D police custody suite model.
4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.

Upon careful reflection, I consider that the second and third concerns are pertinent to WMP, whereas the first and fourth concerns are of relevance to other addressees of the Regulation 28 report, namely: (i) Chief Executive NHS England; (ii) Chief Executive Birmingham and Solihull Mental Health Trust and/or (iii) The Rt Hon Priti Patel MP, Home Secretary.

In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.

However, I understand that the Chief Executive of BSMHT will be addressing both of these issues in her response.

For these reasons, this response focuses on the second and third concerns identified by HM Area Coroner for Birmingham and Solihull. In order to ensure that the second and third concerns are comprehensively addressed and bearing in mind “the ‘gap’ in commissioning” identified in the Regulation 28 report, WMP has engaged with BSMHT prior to preparing this response.

In relation to the second concern, the mental and physical wellbeing of detainees is a matter for which the Chief Constable is ultimately responsible. This is a matter upon which both WMP and BSMHT are clear. However, it is important to note that this responsibility does not necessarily entail the direct recruitment of medical or mental health clinicians. As is common in custody provision across England, there is an expectation that locally commissioned health provision will be available to detainees in the same way that it would for members of the public who are not in detention. While it is my responsibility to maintain the welfare of detainees, this responsibility is discharged by establishing adequate processes and delivering appropriate training and direction to custody officers/staff about when and how to access clinical support.

Turning to the third concern, following the evidence adduced at the inquest, it is acknowledged that the understanding of some WMP custody officers/staff in relation to the role and limitation of L&D requires improvement. Given that custody officers/staff are not medically trained, it is reasonable for them to be able to rely on, and defer to, the professional opinion of healthcare practitioners in relation to matters of mental and physical health. At the same time, it is accepted that custody officers/staff need to understand the differing levels of expertise of various clinicians and healthcare practitioners. It is also clear from the inquest that custody officers/staff need to understand that even in circumstances where an assessment is made by a suitably qualified clinician at a specific point in time, they should always feel able to question and request a review of that decision if and when further information becomes available.

For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:

• The creation of a formal escalation process for when custody staff/officers believe that an L&D decision is wrong. This escalation process will ensure custody officers/staff dealing with such situations make better use of the Mental Health Tactical Advisors who have access to a detained person’s mental health history through partners, and have a better degree of knowledge/understanding of these issues and may therefore be better placed to review the L&D decision;
• A review of the training provided to custody officers/staff specifically in relation to mental health issues;
• Provision of clear and unequivocal advice to all front-line staff as to the nature, scope and limitations of the current L&D function.

I hope that this response reassures HM Area Coroner for Birmingham and Solihull that the matters of concern that have been raised in the Regulation 28 report are being addressed.

Home Secretary 2 Marsham Street London SW1 P 4DF Home Office

' James Bennett HM Area Coroner Birmingham & Solihull Areas Steelhouse Lane Birmingham B4 SBJ

h~ January 2023 Thank you for your letter of 15 November 2022 regarding the Regulation 28 Report to Prevent Future Deaths which was sent to the former Home Secretary, the Rt Hon Priti Patel MP. I would like to express my sympathies to the family of Khalid Seneen Yousef. I also wish to apologise for the very long delay in responding to you about this report. I have asked my office to investigate the circumstances surrounding your previous correspondence of June, September and October which we have no record of receiving. I note that you have already received detailed responses from the Chief Constable of West Midlands Police and from the National Medical Director of NHS England in response to your concerns. The commissioning of Liaison and Diversion Services is a matter for NHS England. The tendering and commissioning of all police custody healthcare services is the responsibility of Police and Crime Commissioners and their forces and it is for them to take decisions on how to allocate resources based on their local knowledge and experience. Therefore, it would not be appropriate for the Home Office to comment or intervene in either of these two services. I can confirm that NHS England continues to provide national support and oversight to the National Police Chiefs' Council (NPCC) in respect of healthcare being delivered in police custody suites, which includes maintaining the integrity and standards for the NPCC Police Custodial Healthcare Service Specification and its alignment with NHS England's Liaison & Diversion national service specification. This supports NHS England's undertaking to voluntarily provide support to our colleagues in policing. NHS England confirm, that to the best of their knowledge the service specification is used by all forces as part of their tendering for new custodial services and is regularly reviewed by a variety of stakeholders including the Faculty of Forensic and Legal Medicine and other distinguished medical experts and police custody leads, in order to ensure that any policy or legislative changes are reflected.

It is reassuring to note that West Midlands Police acknowledge that operational improvements can be introduced in respect of your findings in the report. It is important to also note that in addition to those changes, that when someone passes the threshold from the Liaison and Diversion service to identify, assess and report on a person's vulnerability and moves towards a crisis situation the police can seek a Mental Health Act assessment via the local authority duty. This process can be supported by the police healthcare provider and by the Liaison and Diversion service on a voluntary and supportive basis within current service specifications. I can also confirm that Home Office officials work very closely with the NPCC, NHS England, the Department for Health and Social Care on a range of different issues relating to mental health and how healthcare partners and the police can work together most effectively. Currently, they are collectively working on how to improve escalation processes between the police and NHS and how mental health is managed in the custody environment with a view to the NPCC issuing guidance on effectively managing these referral pathways. I trust that this provides some reassurance to you. Rt Hon Suella Braverman KC MP