Recurance · prevention of future deaths reports
Pre-inquest brief
Incorrect section placement and missing information during assessments
The earlier warning
Leah Ratheram · 15 Mar 2017 · Louise Hunt, Birmingham and Solihull
“An approved social worked declined to be involved until the assessment had been completed.”
judiciary.uk/prevention-of-future-death-reports/leah-ratheram
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 10 Sept 2019 · Gurdeep Singh Dundhal · Louise Hunt · Closely related · confidence 0.92 (high)
- 4 Mar 2025 · Matthew Lynch · Louise Hunt · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.