Incorrect section placement and missing information during assessments

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2017 → 2019Gurdeep Singh Dundhal2 years 6 months after Leah Ratheram · same coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight that insufficient or unavailable information during Mental Health Act assessments compromises assessment quality and patient safety. The earlier report notes missing specialist input and poor information sharing; the later report documents missing key information and documentation at assessment.

  Leah Ratheram · 15 Mar 2017

  “An approved social worked declined to be involved until the assessment had been completed.”

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  Gurdeep Singh Dundhal · 10 Sept 2019

  “Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19.”

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  Earlier report in the app · Later report in the app

• 2019 → 2025Matthew Lynch5 years 6 months after Gurdeep Singh Dundhal · same coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight problems with the application of Sections 2 and 3 of the Mental Health Act due to decisions or resistance by Approved Mental Health Practitioners. The earlier report cites a specific incorrect section placement, while the later report describes broader barriers to using those sections.

  Gurdeep Singh Dundhal · 10 Sept 2019

  “When Mr [name redacted] was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3.”

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  Matthew Lynch · 4 Mar 2025

  “Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”

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  Stated action in the response to the earlier report

  “We will continue to engage with other agencies to enable the Trust to learn from incidents and improve patient care.”

  Earlier report in the app · Later report in the app

• 2017 → 2025Matthew Lynch8 years after Leah Ratheram · same coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight problems with the Mental Health Act assessment process that could lead to unsafe or incorrect detentions. The earlier report focuses on missing early involvement of approved social workers, while the later report points to AMPH resistance, administrative and resourcing barriers affecting S2/S3 use.

  Leah Ratheram · 15 Mar 2017

  “The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”

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  Matthew Lynch · 4 Mar 2025

  “there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”

  Check it in the source

  Earlier report in the app · Later report in the app