Recurance · prevention of future deaths reports
Pre-inquest brief
Missing mental health hand‑over in custody
The earlier warning
David Jukes · 12 Jul 2019 · Emma Brown, Birmingham and Solihull
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
judiciary.uk/prevention-of-future-death-reports/jonothan-jukes
What was promised
Stated action 1 · 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 2 · 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.”
Stated action 3 · response to David Jukes (12 Jul 2019) · stated timescale: end of March 2020
“High quality care for all, now and for future generations”
6 further stated actions are listed on the full chain page.
What recurred
- 23 Jun 2022 · Khalid Yousef · James Bennett
- 9 Jul 2024 · Miles Hurley · Karen Henderson · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · David Jukes · 12 Jul 2019
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
Later · Miles Hurley · 9 Jul 2024
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
What happened next
No web check of the stated actions has been published for this chain.