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recurance

Incomplete paperwork and missing responsible clinician for section 5(2) holds

Closely relatedConfidence 0.85 · high2 reports · 2022–2024 One-page brief (print or PDF)

NHS England received 2 coroners' reports about this hazard between 19 Dec 2022 and 19 Jun 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 2 specific actions.

2
reports
2
different coroners
2022–2024
years
0.85
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Mollie Stansfield↗

    19 Dec 2022 · Paul Marks · East Riding and Hull

    “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect.”
    Original on judiciary.uk ↗

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “response, are providing the required guidance and training to all medical professionals who hold these important powers”
    “I am therefore taking steps to raise this issue with HSC Trust Chief Executives and relevant professional bodies, in order to ensure that the appropriate action is taken to address this point.”
  2. 1 year 6 months later

    Raised again · 1st time

    Aaron Deeley↗

    19 Jun 2024 · Sonia Hayes · Essex

    Closely relatedConfidence 0.85 · higha different coroner
    “Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:MentalHealthsectionholdingpower

    NHS England responded.Response (PDF) ↗

  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