Dear Sir,

Prevention of Future Deaths report dated 12 August 2024, Parminder Singh Sanghera

I write in response to the Prevention of Future Deaths report dated the 12 August 2024 which followed on from the inquest touching upon the death of Mr Parminder Singh Sanghera. The report identified three key areas of concern to be addressed.

1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station.
2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time.
3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.

This letter is the response on behalf of the Chief Constable of West Midlands Police (WMP). I am Chief Superintendent , Head of Criminal Justice Services at West Midlands Police. I hold responsibility for the custody portfolio. Health and Justice (previously Liaison and Diversion). Although, Health and Justice is an NHS commissioned service, located within WMP custody suites.

Health and Justice

Keeping our Communities Safe and Reassured

Working in partnership, making communities safer

STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES

Director of Legal Services

Your Ref:

Our Ref:

Email:

Date: 27 September, 2024

2

Where a person is arrested for a Police and Criminal Evidence Act 1984 (PACE) matter and there are concerns that they are in mental health crisis, they will usually be referred to both a healthcare professional (‘HCP’) and Health and Justice, or Health and Justice alone, depending on the individual circumstances.

Pursuant to the above, Mr Sanghera was referred to an HCP to assess his fitness to be detained. The HCP noted that he was calm and compliant, making good eye contact and speaking in coherent sentences. He stated he had been hearing auditory voices for a few weeks but had no deliberate self-harm (DSH) or suicidal ideation at the time of the assessment. A plan was made for him to be referred to Liaison and Diversion the following morning (13 February
2023).

The role of Liaison and Diversion is to undertake screenings and assessments for a range of health and social care needs and other vulnerabilities in order to ensure those needs are being adequately addressed, to provide diversionary opportunities and ensure key decision makers within Criminal Justice Services (CJS) have sufficient understanding to make an informed decision.

Liaison and Diversion staff (Community Psychiatric Nurses) were engaged by the custody sergeant on the day of Mr Sanghera’s release. They decided, after screening him, not to attend and speak to him. This was due to the fact he had been assessed by mental health services on the 9 and 12 February 2023. No acute mental health concerns and/or self-harm/suicidal intent had been noted during these assessments. Mr Sanghera had been referred back to his GP with an update to be provided to his current care provider.

A decision was made by the investigation team that the offence Mr Sanghera was arrested for would be subject to No Further Action (NFA). Therefore, the power to legally detain Mr Sanghera in police custody under the provisions of PACE ceased. The criteria for continued detention to allow for a full assessment by an approved mental health professional and doctor under s136(2) of the Mental Health Act 1983 (MHA), namely that the person appears to be suffering from a mental disorder and in need of immediate care and control, was not met. In a custody setting, this assessment is made by a custody sergeant in consultation with a registered medical practitioner.

A pre-release risk assessment was conducted and Mr Sanghera was released from custody. The process followed by the staff involved in Mr Sanghera’s detention adhered to the requirements of PACE, Approved Professional Practice (APP) and the WMP Custody Standard Operating Procedure (SOP).

Where it is determined that a full mental health assessment is necessary pursuant to s136 MHA, it is normal practice for Health and Justice to coordinate this being conducted (during working hours). Outside of working hours this is coordinated by the custody healthcare provider, Mitie.

In the event that the PACE matter is finalised prior to this assessment being conducted, circumstances will be considered on a case by case basis but it is usual practice for the person

3

to be detained under s136 MHA. WMP officers are accustomed to applying the s136 criteria; as a force, we see particularly high volumes of s136 detentions within the custody environment.

Changes since 13 February 2023

Since the date of Mr Sanghera’s death, there have been a number of measures introduced within the custody environment aimed at continuously improving the level of care detained persons receive. These are not solely in response to the death of Mr Sanghera, but as part of the continuous improvement of the custody function service within WMP.

These improvements include:

(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training; (ii) Pre-release risk assessments are now subject to monthly audits to ensure quality; (iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response; (iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number. With the written consent of the detained person Mitie can then access further details covering current allergies; current acute and repeat medications; and discontinued medications. The system would not show why the detained person was on those medications. Sometimes a medical condition will be recorded for example epilepsy, asthma or diabetes. Mitie cannot access GP notes. Not everyone has Summary Care Records. For example, detained persons who are not UK residents or not registered with a GP. (v) WMP is working with the Birmingham and Solihull Mental Health Trust, providing them access to Perry Barr custody suite which will enable them to identify and fill any gaps in the provision of mental health services within the custody arena, and expand available service pathways from this setting; (vi) Under “Right Care, Right Person”, WMP is working closely with mental health partners, again with the ambition to bring mental health services into the custody environment. This will ensure access to the appropriate service at the earliest opportunity, and enable officers to determine, at each stage of a person’s detention, whether that person’s health needs or the investigation takes primacy.

The ultimate objective is to deliver a system wide response to those in mental health crisis.

4

If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me.

Dear Mr Siddique,

We have been asked to assist Royal Wolverhampton NHS Trust (“the Trust”) in relation to your Regulation 28 Report to Prevent Future Deaths (PFD) dated 12 August 2024. The PFD followed the inquest of Mr Parminder Singh Sanghera and it is our understanding that it was addressed to the Chief Executive at the Trust as being a person with the power to take relevant action in relation to the concerns raised in the PFD.

Those concerns are that no Mental Health Act Assessment took place at New Cross Hospital or whilst Mr Sanghera was in custody and have suggested that the Trust might wish to review arrangements required before discharge from hospital.

As you are aware, the Trust was not an Interested Person at the inquest (but provided factual witness evidence) and did not have the opportunity to make representations to the Coroner regarding the way in which mental health services are provided. It did not have an opportunity to address any concerns subsequently set out in, the PFD.

Whilst the Royal Wolverhampton NHS Trust (the Trust) is committed to delivering an excellent standard of care to all patients, including those with mental disorders/illness, it does not deliver direct mental health services or mental health intervention and does not provide any mental health services. The Trust does however, make referrals to the Mental Health Liaison Service which is provided by the Black Country Healthcare NHS Foundation Trust.

The Emergency Department at New Cross Hospital has a clear procedure in place for patients whose behaviour is causing concern without an identified medical cause (see Document 1 attached), This involves a referral to the Mental Health Liaison Service (see Referral Form, Document 2 attached). This service is available 24/7 and has response time of within 1 hour.

The Mental Health Liaison Service aims to provide acute mental health assessment, treatment and support to individuals in New Cross, West Park and Cannock Chase

Hospitals, this includes patients treated in the Emergency Department and assessed as medically fit for discharge. Part of the Liaison Service’s role is to assess acute mental health needs and ensure that they receive the help that they need, including undertaking a formal Mental Health Act Assessment with a view to detention under section 2 or section 3 if considered to be necessary . The referral criteria includes individuals who have “deliberately caused harm to themselves by overdose of medication or by other methods with suicidal intent”.

On the two occasions during February 2023, the 9th and the 11th when Mr Sanghera attended the Emergency Department, a referral was correctly made to the Mental Health Liaison Service provided by the Black Country Healthcare NHS Foundation Trust in accordance with Trust protocol and he was assessed by them. On the 2 early occasions they determined that he did not have a mental disorder (therefore not requiring a Mental Health Act assessment) with a view to being fit for discharge. The Trust therefore do not have the power to determine next steps in relation to a patient’s mental health concerns when input has been sought appropriately from the menta health service.

Further, on the latter attendance the 12th February, the Trust does not provide any mental health “input” in relation to those in police custody. It is understood that this would be provided by the Liaison and Diversion Service – which will be organised at a local level between the police and mental health services and is subject to a Memorandum of Understanding between services. Again, this is not something that the Trust would have any involvement in.

We believe that the Coroner may be directing his concerns regarding mental health services to the wrong trust, however the Trust does wish to respond to the PFD as comprehensively as possible and to assist in clarifying how the various services interact. As the Coroner will see there is no further relevant action within the Trust’s power which could have been taken by the Trust to address the Coroner’s concerns set in the PFD.

We hope you find this response comprehensive. If you require any further information, please let us know.

Legal Director Weightmans LLP