Lack of mental health risk assessment training and timely referrals
Surrey Police received 2 coroners' reports about this hazard between 24 Nov 2014 and 18 Sept 2024.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
Original on judiciary.uk ↗ Surrey Police responded, stating 1 specific action.Response (PDF) ↗
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”
Stated timescale: January 2015
- 9 years 10 months laterClosely relatedConfidence 0.90 · higha different coroner
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealth
Surrey Police responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Surrey Police
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.
2014 → 2024Helen Kerr9 years 10 months after William Hafele · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in assessing mental health risk: the earlier cites lack of training for risk assessments, the later notes that clear information about declining mental health was not explored or weighted in triage.
William Hafele · 24 Nov 2014
“- In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking”
Original on judiciary.uk ↗ Helen Kerr · 18 Sept 2024
“(1) Cogent information about Ms [name redacted] declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”
Stated action · timescale: January 2015
“The Force's Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility: e the risk assessment process to identify whether people missing from mental health and medical care establishments should be categorised as being low, medium or high risk as identified by certain criteria; and e the responsibility for identified enq”
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 Surrey Police 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 |
|---|---|---|---|---|
| 2014 → 2024 | 0.67 | 0.09 | Closely related · 0.90 | 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.