QB-2022-002447 - [2025] EWHC 2803 (KB)

On the date of the alleged breaches, shortly after midnight 14 August 2018, several police officers attended and found C3 in the garden pacing around with his shirt off, rambling and swearing. A police note stated that in the view of the officer C3 was in urgent need of an assessment and that a mental health setting was more appropriate than police custody.  

Just after 8.00 AM on 14 August 2018, C1 updated D2’s day treatment team about events, including the arrest of C3. A registered mental health nurse saw C3 in his cell at 10.00AM. C3 denied the incident for which he had been arrested, and claimed his mother had been overreacting. The nurse assessed the risk as “medium,” and stated in the note he made that C3 had “sufficient insight into the current situation”, but said he would benefit from a further assessment by the AMHP team to decide whether compulsory admission was necessary. 

Arrangements were made for C3’s assessment to be conducted by two clinicians, approved under s.12 MHA, that is to say D3 and D4. An AMHP (accepted for the purposes of this application as employed by D1) also attended.  Neither D3 nor D4 was employed by or affiliated to either D1 and/or D2. They had no background knowledge of C3’s mental health difficulties. At around 2 PM on 14 August 2018, the two doctors D3, D4 and the AMHP, conducted an assessment of C3.

The assessment concluded that C3’s mental state did not satisfy the statutory criteria for compulsory detention pursuant to s. 2 MHA. At 17:51 C3 gave a no comment interview to the Police, and at 18:35 a decision was taken to take no further action; C3 was released from Police custody.

 The relevant notes of the encounter of C1, C3’s mother, with the AMHP show the AMHP had a discussion with her and reviewed the custody record. The AMHP was aware of the incident earlier that day, and she had a discussion with C3. The record of the AMHP, held by D2, continues as follows: 

On 15 August 2018, a Care Programme Approach Initial Assessment was opened by D2.  It is the Claimants’ case that no assessment took place and there was no follow up. On 17 August 2018, the psychiatrist who had examined C3 on 9 August wrote to C3’s GP saying he considered C3 a probable suicide risk. On 22 August 2018, C1 called D2’s Harrow Community Mental Health Team (“CMHT”). A voicemail in response said the case had been closed. On 23 August 2018, C3’s GP phoned the SPA and Harrow CMHT, they were told the case was closed because they had concluded that he was not detainable and no follow-up was planned.  

The Claimants say that through August and September 2018 C3 continued to be very abusive toward C1 and deteriorated.  C1 phoned the Police after C3 attempted to cut his wrists on 17 September 2018, but no further support was offered. C1 reported to his GP that C3 was increasingly violent and the doctor made an urgent 24-hour referral saying C3 was at high risk of violence and aggression and there were safeguarding concerns for his mother and sister.   On 21 September 2018 C1 called Harrow CMHT’s duty social worker twice to express her concerns. The duty social worker spoke to the AMHP and the Duty Manager. By agreement, they told C1 to phone the Police if C3 became violent and provided her with details of a domestic violence charity, saying the case would be discussed in the team next week. The recorded plan was to “hand over to Duty Manager”.  Between 24 September and 26 October 2018, C1 made several more attempts to report C3’s deteriorating mental health and fear for her own safety. On 26 October 2018, a trainee GP and worker from the local Drug and Alcohol Service attended the family home to assess C3 but he was not at home. On 5 November 2018 the case was officially closed. The GP was notified on 16 November 2018. 

The Claimants say that during the period from the closure of C3’s case until the violent incident on 23 December 2018, there was no material change in C3’s behaviour.