Missing mental health hand‑over in custody
NHS England received 3 coroners' reports about this hazard between 12 Jul 2019 and 9 Jul 2024.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 13 specific actions.
The story, report by report
Spacing grows with the time between reports.
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
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 later
“West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.”
Original on judiciary.uk ↗ 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.
- 2 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
Original on judiciary.uk ↗ NHS England responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.”
“It is recognised that there is a lack of information being recorded on custody detention logs. The College of Policing Hydra packages are in place to improve this and the NPCC are supportive of this training for custody staff. I understand that Sussex Police have now adopted this training.”
2 more stated actions in the Promises tab.
- 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.
2019 → 2024Miles Hurley5 years after David Jukes · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in communicating mental health information between liaison services and police in custody settings. The earlier case concerns missing patient history hand‑over, while the later case notes absent documentation and communication between the Liaison Diversion Service and police.
David Jukes · 12 Jul 2019
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
Original on judiciary.uk ↗ Miles Hurley · 9 Jul 2024
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
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”
2022 → 2024Miles Hurley2 years 1 month after Khalid Yousef · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight problems at the interface between police custody and liaison/diversion services concerning information sharing and role clarity.
Khalid Yousef · 23 Jun 2022
“West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.”
Original on judiciary.uk ↗ Miles Hurley · 9 Jul 2024
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
Original on judiciary.uk ↗
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.
Stated action
“The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.”
Stated action
“It is recognised that there is a lack of information being recorded on custody detention logs. The College of Policing Hydra packages are in place to improve this and the NPCC are supportive of this training for custody staff. I understand that Sussex Police have now adopted this training.”
Stated action
“Guidelines around supporting a LDS Practitioner as to when it is appropriate to undertake a formal mental health assessment when an individual is intoxicated is a matter for the LDS provider.”
Stated action
“National guidelines are in place in the form of PACE Code C in relation to identifying vulnerability in police custody and the provision of an Appropriate Adult. It is not clear from the information in the report as to why the interviewing officer did not deem the support of an Appropriate Adult for Mr [name redacted] necessary in this case.”
- 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 |
|---|---|---|---|---|
| 2019 → 2024 | 0.76 | 0.19 | Closely related · 0.90 | different |
| 2022 → 2024 | 0.77 | 0.17 | Closely related · 0.80 | 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.