Missing mental health assessment in police custody
NHS England received 4 coroners' reports about this hazard between 17 Feb 2017 and 8 Jun 2023.
They came from 4 different coroners in 3 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 10 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Web search (Tavily): Evidence found that the action was carried out
Health and Justice Commissioning Intentions 2015/16 ↗- 2 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“Despite not being informed by the BCPFT liaison and diversion nurse that Mr [name redacted] was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018.”
Original on judiciary.uk ↗ NHS England responded, stating 6 specific actions.Response (PDF) ↗
“NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person's presentation at the point of arrest, if relevant.”
Stated timescale: end of March 2020
“We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports.”
Stated timescale: end of March 2020
4 more stated actions in the Promises tab.
- 2 years 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“The L&D police custody suite model has not commissioned psychiatrists.”
Original on judiciary.uk ↗ Repeated from the earlier report:policecustody
NHS England responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“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”
Stated timescale: end of October 2022
“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”
Stated timescale: end of October 2022
1 more stated action in the Promises tab.
- 11 months laterClosely relatedConfidence 0.92 · higha different coroner
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen.”
Original on judiciary.uk ↗ - All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2019David Jukes2 years 5 months after Dean Saunders · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures to ensure mentally disordered individuals held in police custody receive appropriate mental health assessment or transfer. The earlier report points to a missing admissions protocol, while the later report describes a breakdown in communication that prevents timely assessment.
Dean Saunders · 17 Feb 2017
“The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”
Original on judiciary.uk ↗ David Jukes · 12 Jul 2019
“Despite not being informed by the BCPFT liaison and diversion nurse that Mr [name redacted] was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018.”
Original on judiciary.uk ↗ 2017 → 2022Khalid Yousef5 years 4 months after Dean Saunders · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a gap in mental‑health provision for individuals detained in police custody, specifically the absence of psychiatrists or proper transfer protocols.
Dean Saunders · 17 Feb 2017
“FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”
Original on judiciary.uk ↗ Khalid Yousef · 23 Jun 2022
“The L&D police custody suite model has not commissioned psychiatrists.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
2019 → 2022Khalid Yousef2 years 11 months after David Jukes · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight the absence of psychiatrist assessment for individuals in police custody as a risk to life. The earlier case focuses on missed visits due to poor information flow, while the later case points to a systemic lack of commissioned psychiatrists in the custody model.
David Jukes · 12 Jul 2019
“Despite not being informed by the BCPFT liaison and diversion nurse that Mr [name redacted] was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018.”
Original on judiciary.uk ↗ Khalid Yousef · 23 Jun 2022
“The L&D police custody suite model has not commissioned psychiatrists.”
Original on judiciary.uk ↗ 2019 → 2023Ivan Ignatov3 years 11 months after David Jukes · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight that a mental health assessment was not carried out for a person while they were in police custody, despite indications that one was needed. The earlier case involved a missing psychiatrist visit; the later case involved a missing face‑to‑face assessment by a mental health practitioner.
David Jukes · 12 Jul 2019
“Despite this, no psychiatrist visited or attempted to visit Mr. [name redacted] in custody which it was stated in evidence was the usual practice of the team.”
Original on judiciary.uk ↗ Ivan Ignatov · 8 Jun 2023
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“implementing a documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter”
Stated action
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
What happened next: Evidence found that the action was carried out
The document indicates that NHS England is involved in commissioning healthcare for police custody, including plans to transfer responsibility by 2016.
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
Stated action · timescale: end of March 2020
“NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person's presentation at the point of arrest, if relevant.”
Stated action · timescale: end of March 2020
“We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports.”
Stated action · timescale: end of March 2020
“High quality care for all, now and for future generations”
Stated action · timescale: summer 2020
“Connect will be available in custody”
Stated action · timescale: summer 2020
“three liaison and diversion teams will have access to partitioned parts of the police system that helps them understand the context of the persons arrival into custody and more information about historical custody appearances.”
Stated action · timescale: summer 2020
“All liaison and diversion teams have had information sharing training and this training offer has also been made to Police Healthcare providers”
Stated action · timescale: end of October 2022
“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”
Stated action · timescale: end of October 2022
“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”
Stated action · timescale: 31 December 2022
“the Home Office or the NPCC would be best placed to respond to specific concerns in this case”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2019 | 0.76 | 0.15 | Closely related · 0.90 | different |
| 2017 → 2022 | 0.71 | 0.18 | Closely related · 0.90 | different |
| 2019 → 2022 | 0.80 | 0.13 | Closely related · 0.85 | different |
| 2019 → 2023 | 0.79 | 0.13 | Closely related · 0.92 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.