Inquest held touching on the death of a man following section 136 detention and police custody- PFD Issued regarding correct process for assessment prior to discharge from s136 detention


Inquest into the death of a man with complex mental health issues, including Post-Traumatic Stress Disorder (PTSD) and Emotionally Unstable Personality Disorder (EUPD). Representing the family of the deceased, this inquest involved in-depth cross-examination including the conclusions of a section 12 approved psychiatrist, an Approved Mental Health Professional (AMHP) and police officers. Following this inquest and the narrative verdict which followed, the Assistant Coroner issued a Prevention of Future Death Report given concerns as a result of an incorrect interpretation of the Mental Health Act 1983 Code of Practice. This inquest highlighted the custom and practice of individuals being discharged from detention under section 136 of the Mental Health Act following assessment solely by a lone section 12 approved doctor if they concluded that an individual is not suffering from a mental disorder. This discharge could therefore take place without the examination by an AMHP, in contravention of the MHA, which risked exposing vulnerable individuals to a risk of death or self-harm, thereby leading the AC to issue a PFD.

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