The MATTERS OF CONCERNS are as follows: 5.1 I received evidence from Ms. Spence and Ms. Pawson of the Mental Health Care Trust as follows. 5.2 Joshua had been known to mental health services (MHS) since about 2018. He was again referred to MHS on 26.06.21 and was made subject to an order for assessment under S2 Mental Health Act 1983 (MHA) on 26.07.21. He was discharged to the Sheffield Home Treatment Team on 11.08.21. 5.3 A mental health nurse, Ms. Spence, was allocated on 31.08.21. 5.4 The view was reached on 18th August 2021 that Joshua’s deteriorating mental health and level of risk meant that he should be assessed for detention for assessment under s2 MHA. This was not actioned until 26th August 2021. On that date, a warrant was applied for which contained errors which invalidated it. Nevertheless, Joshua was assessed, and the decision taken that he did not require a section as at that date. 5.5 Joshua hanged himself on 29.09.21. 5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future.

5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. 5.8 I require you to report explaining (1) what action will be taken to prevent the risk of deaths while a person who is recommended for assessment for section is waiting for the assessment to take place and (2) what action will be taken to eliminate such waits for assessment.