Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of mental health act assessment before release
The earlier warning
Richard Carlon · 22 Jul 2019 · Louise Hunt, Birmingham and Solihull
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
judiciary.uk/prevention-of-future-death-reports/richard-carlon
What was promised
Stated action 1 · response to Richard Carlon (22 Jul 2019) · stated timescale: by November 2019
“West Midlands Police will ensure any caller is updated when a missing person has been located to allow further contact between parties. This may not always mean full details of whereabouts are disclosed (as individual cases may prevent this from being appropriate) however, the reasons for this will be recorded and explained in each case.”
judiciary.uk/…/2019-0287-Response-by-Staffordshire-and-West-Mid…
What recurred
- 12 Aug 2024 · Parminder Sanghera · Zafar Siddique · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Richard Carlon · 22 Jul 2019
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Later · Parminder Sanghera · 12 Aug 2024
“During the course of the inquest, I heard evidence Mr [name redacted] was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station.”
What happened next
No web check of the stated actions has been published for this chain.