Kirsty Walker
19 Dec 2018 · Coroner Anna Crawford · Surrey
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed transfer to secure hospital
“I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The court heard that where a prisoner is assessed as being detainable under the Mental Health Act 1983, they ought to be transferred to hospital within 14 days, pursuant to the recommendations in the 2009 Bradley Report.”
Later report
“The evidence I received established that, despite changes made since the Deceased's death, including the recent introduction of NHS England's "Mental Health Crisis Care for Londoners: London's Section 136 Pathway and Health Based Place of Safety Specification", it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit.”
Responses
2018-0396-Response-by-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2018-0396-Response-by-NHS-England.pdf ↗· NHS England
Stated action · end of May 2019
“The next audit is currently underway, based on a census date of 28 February 2019. It is anticipated that the report will be available by the end of May 2019.”