Recurance · prevention of future deaths reports
Pre-inquest brief
Missing mental health assessment in police custody
The earlier warning
Dean Saunders · 17 Feb 2017 · Caroline Beasley-Murray, Essex
“The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody.”
judiciary.uk/prevention-of-future-death-reports/dean-saunders
What was promised
Stated action 1 · response to Dean Saunders (17 Feb 2017) · stated timescale: none stated
“The following information describes the commissioning arrangements for healthcare for someone being held in police custody.”
Stated action 2 · response to David Jukes (12 Jul 2019) · stated timescale: end of March 2020
“NHS England and NHS Improvement will work with police forces to ensure that all relevant information from a police perspective is given to the liaison and diversion practitioner, including the nature of the detained person's presentation at the point of arrest, if relevant.”
Stated action 3 · response to David Jukes (12 Jul 2019) · stated timescale: end of March 2020
“We will commit to a national event by the end of March 2020 to debrief on this matter and any other information sharing/exchange issues that have been raised in other reports.”
7 further stated actions are listed on the full chain page.
What recurred
- 12 Jul 2019 · David Jukes · Emma Brown · Closely related · confidence 0.90 (high)
- 23 Jun 2022 · Khalid Yousef · James Bennett · Closely related · confidence 0.90 (high)
- 8 Jun 2023 · Ivan Ignatov · Rachael Griffin · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · David Jukes · 12 Jul 2019
“Despite this, no psychiatrist visited or attempted to visit Mr. [name redacted] in custody which it was stated in evidence was the usual practice of the team.”
Later · Ivan Ignatov · 8 Jun 2023
“During his time in police custody, it was identified by the custody sergeants that [the deceased] required a face to face assessment by the mental health practitioner. This did not happen.”
What happened next
Evidence found · stated action 1
“The commissioning of Healthcare for Police Custody Suites is to transfer to NHS England by 2016. This work will continue to be developed and”
Health and Justice Commissioning Intentions 2015/16 · england.nhs.uk/…/hj-comms-ints-refresh.pdf