Lack of mental health act assessment before release
West Midlands Police received 2 coroners' reports about this hazard between 22 Jul 2019 and 12 Aug 2024.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ West Midlands Police responded, stating 1 specific action.Response (PDF) ↗
“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.”
Stated timescale: by November 2019
- 5 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“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.”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealthassessment
West Midlands Police responded.Response (PDF) ↗Response (PDF) ↗
- All reports to West Midlands 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.
2019 → 2024Parminder Sanghera5 years 1 month after Richard Carlon · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures to conduct a proper Mental Health Act assessment when individuals were experiencing a mental health crisis. The earlier case cites unavailability of approved practitioners, while the later case notes misclassification of behaviour preventing assessment.
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.”
Original on judiciary.uk ↗ 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.”
Original on judiciary.uk ↗
Stated action · 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.”
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 West Midlands 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 |
|---|---|---|---|---|
| 2019 → 2024 | 0.68 | 0.16 | 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.