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recurance

Misunderstanding of section 135 mental health act powers

Closely relatedConfidence 0.80 · moderate2 reports · 2019–2026 One-page brief (print or PDF)

NHS England received 2 coroners' reports about this hazard between 31 Jul 2019 and 24 Apr 2026.

They came from 2 different coroners in 2 coroner areas. 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 0 specific actions.

2
reports
2
different coroners
2019–2026
years
0.80
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Nigel Abbott↗

    31 Jul 2019 · James Bennett · Birmingham and Solihull

    “there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation”
    Original on judiciary.uk ↗

    NHS England responded.Response (PDF) ↗

  2. 6 years 9 months later

    Raised again · 1st time

    Edward Muwanga↗

    24 Apr 2026 · Paul Rogers · Inner West London

    Closely relatedConfidence 0.80 · moderatea different coroner
    “A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant”
    Original on judiciary.uk ↗
  3. All reports to NHS England

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error