Gurdeep Singh Dundhal

1. 1. delay in assessment of Mr Dundhal

   “There was a delay in organising the assessment of Mr [name redacted] when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was to undertake the assessment between Walsall MBC and Birmingham City Council. In addition there was a lack of resources to enable the assessment to be carried out in a timely manner. This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.”

2. 2. lack of information during assessment

   “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. I was unable to confirm which at the inquest. This meant the true nature of Mr [name redacted] long term condition was not known and the assessors were unable to see the”

3. 3. placement on S2 instead of recommended S3

   “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. No explanation was available for this. Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation.”

4. 4. failure to investigate and share lessons

   “Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.”

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