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Police Custody as "a Place of Safety" Examining the use of Section 136 of the Mental Health Act 1983

CR149 Standards on the use of Section 136 of the Mental Health Act 1983 (2007) - (version for England)

the safer detention & handling of persons in police custody 2006 guidance

Death Report

Police Realted Deaths

CSV Report

Memorandum of Understanding

Deaths in Custody

Mental Health and Policing

Mental Health is a factor in many of the most serious cases of police misconduct investigated by the IPCC. Over 50% of deaths in police custody are of people with some form of mental health problem. 

PCA 5 year death study: 1998-2003

The IPCC is working to make sure that:

  • police officers and staff have the skills, training and support to care for any specific needs a person with mental health problems may have
  • police custody is not used inappropriately as a place to care for people with mental health needs
  • health, social services and other parts of the mental health picture are working well nationally and locally with police.

What is the IPCC doing?

Through police complaints cases and talking to voluntary, police and statutory groups, the IPCC has identified specific areas of work:

Read our evidence to the Joint Committee on the Draft Mental Health Bill

Policing and Mental Health: Risks and Realities

20 Jan 05

This seminar was aimed at people working in the police and health/social care services as well as the voluntary sector, and aimed to identify better services for people with serious mental health needs who get caught up inappropriately in the criminal justice system, by improving the risk management and interagency working of the key organisations facing this major challenge.

The seminar also examined the especially adverse experience and specific needs of people from black and minority ethnic backgrounds. For more information please see the Conference Material and final report

The IPCC is developing its work on Mental Health through an internal strategy group of operational staff. The work is being led by John Crawley, Central Region Commissioner.

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remember your rights on arrest notice of entitlements

Dear Chief Officer,

This circular advises Chief Officers on the general principles that should be incorporated in working protocols between their force and local health bodies or other local agencies, where those protocols seek to address the management of potentially violent behaviour.

The attached guidance is the result of a wide consultation with ACPO, the Police Staff Associations and other interested stakeholders on the Cross-Government Group, which is working to develop policy on the management of potentially violent behaviour and the use of safer restraint across the criminal justice, correctional and health sectors.

The following guidance complements similar advice to health bodies, which is being developed and promulgated by the National Institute for Mental Health in England and the Counter Fraud and Security Management Service.

The guidance sets out the general principles underlying effective partnership working between local agencies (paragraphs 6 to 8) and stresses the need for senior management to be actively involved. It also provides advice on inter-agency information sharing and confidentiality (paragraphs 9 to 11) and outlines the need for a joint media handling strategy in situations involving issues of wider public interest (paragraph 12).

The underlying issues giving rise to potentially violent behaviour are discussed, with particular emphasis on mental health issues (paragraphs 15 to 18) and substance misuse (paragraphs 19 to20). But the guidance also stresses that sensitive diversity issues, including ethnicity, should be addressed where appropriate in local protocols (paragraph 14). Situations involving miscellaneous issues where police assistance may be requested by health bodies are also covered (paragraphs 21 to 22).

The guidance provides advice on building on best practice (paragraph 23), particularly in regard to debriefing exercises, risk management strategies and shared inter-agency training.

A model local protocol template is provided in Annex A to the guidance, drawing on current examples of best practice and comprising a checklist for reference and discussion when local protocols are being developed and reviewed.

Yours faithfully,

Jenny Maisels

Police Leadership and Powers Unit

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22 September 2005

For Immediate Release

IPCC welcomes coroner’s support at Kerena Thornton inquest

The Independent Police Complaints Commission today welcomed the Coroner’s support for recommendations made at the inquest which concluded yesterday at Brighton Coroners’ Court, Sussex, into the death of Kerena Thornton.

The jury agreed a unanimous verdict of accidental death.

IPCC Commissioner David Petch said: “The tragic death of Kerena Thornton in April 2005 highlighted the issues when the police detain people with mental health problems.

“I believe it is now a priority for the police and health authorities in Sussex to come to early agreement on providing suitable places of safety for such people.”

Mrs Thornton was detained under section 136 of the Mental Health Act (1983) by Sussex Police and taken to Brighton Custody Centre. She subsequently collapsed in her cell and was taken to the Royal Sussex Hospital where she later died.

Sussex Police referred the matter to the IPCC, which managed the Sussex Police investigation. The issues raised in the case were similar to those in the earlier tragic death of Lawrence Tee Hooi Chew from Hove, Sussex. He committed suicide in a second attempt, following a first attempt which had been thwarted by the intervention of police officers.

The IPCC independent investigation into the death of Mr Chew made the following key recommendations:

  • The Police detainee handling centre at Sussex House is not considered as a place of safety for people detained under Section 136 of the Mental Health Act;
  • A review to take place by Sussex Police, Social Services and the Primary Healthcare Trust to find and establish suitable alternative 24 hour facilities at a Mental Health Unit;
  • National policy/guidelines to be issued by the Association of Chief Police Officers.

The Coroner concluded the inquest into Mrs Thornton’s death by supporting the recommendations made by the IPCC and agreed to progress these through Rule 43 of the Coroners’ Rules (1984).


Notes for editors

  • The IPCC is the body with overall responsibility for the police complaints system in England and Wales. It has the task of increasing public confidence in the system and aims to make complaints investigations more open, timely, proportionate and fair. The 17 IPCC Commissioners guarantee the independence of the IPCC and by law can never have served as police officers.
  • Since April 1 2004 the IPCC has used its powers to begin 60 independent and 217 managed investigations into the most serious complaints against the police. It has also set new standards for police forces to improve the way the public's complaints are handled. It has also upheld 313 appeals (out of 934 valid appeals) by the public about the way their complaint was dealt with by the local force.
  • The IPCC is committed to getting closer to the communities it serves. It has regional offices in Cardiff, Coalville, London and Sale plus a sub office in Wakefield. Commissioners are regionally based and supported by 84 independent investigators, as well as caseworkers and specialist support staff.
  • The IPCC web site is constantly updated at or members of the public can contact the IPCC on 08453 002 002

For further information please contact:

David Nicholson, IPCC Press Officer on 020 7166 3250 or the out-of-hours duty press officer on 07717 851157.

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9 June 2005

For Immediate Release

IPCC Concludes West Midlands Mental Health Case

The Independent Police Complaints Commission (IPCC) has called for closer inter-agency working to ensure people with mental health problems in police custody receive appropriate care. It follows an IPCC investigation into complaints made by a woman against the West Midlands Police.

The IPCC launched its investigation following a complaint from a woman concerning her treatment and welfare from her initial contact with police officers until her arrival at hospital.

The incident, in August 2004, arose when West Midlands Police responded to a call from a relative of the woman. Officers attended the scene and arrested the woman in her home in relation to a public order offence. She was taken to Queens Road Police Station in Birmingham.

During her time in police custody the woman attempted to commit suicide on a number of occasions, ending up naked for a period as clothes that could act as ligatures were removed, and was held in police custody for around eight hours in total before being transferred to the Mental Health Unit at the Queen Elizabeth Hospital, Birmingham under section 2 of the Mental Health Act.

The IPCC’s investigation, led by Senior Investigator Tom Henry, found that:

  • Despite all custody staff acting in good faith, the woman’s treatment could, according to legal advice given to the IPCC, amount to a breach of Article 3 of the Human Rights Act 1998 (that ‘no one shall be subjected to [torture or to inhuman or] degrading treatment or punishment.’)
  • No criminal offences were committed by any police officers or staff involved.
  • There were shortcomings in police actions by some officers but these fell short of breaches of the Police Code of Conduct requiring disciplinary action.
  • Existing partnership work between the local police, NHS mental health and primary care trusts and social services should be built upon to address issues of concern that the case raises.
  • John Crawley, IPCC Commissioner for the West Midlands said:

“This case illustrates the inappropriateness of a police station as a safe or satisfactory environment for vulnerable people experiencing acute mental illness.

“It was an extremely difficult and challenging situation that the officers and staff found themselves in. Our investigation has found no evidence that any individual acted without good faith. For that reason, although we have identified shortcomings in relation to the Police Code of Conduct, I have decided that it is appropriate that those involved should receive advice from their local commander rather than formal disciplinary sanctions.”

Mr Crawley went on to say:

“I have already begun discussions with senior officials from the police, local NHS Trusts and social services to see how we can minimise the risk of a similar situation occurring in the future.”

Mr Crawley has also formally invited the Chief Constable and West Midlands Police Authority to review the implications of the legal advice provided to the IPCC that the circumstances arising in this case could amount to a breach of a person’s human rights and to set out the specific actions to be taken to avoid any repetition in similar circumstances in the future.


Notes for editors

  • The Independent Police Complaints Commission (IPCC) is the body with overall responsibility for the new police complaints system in England and Wales.
  • The IPCC is committed to getting closer to the communities it serves. It has regional offices in Cardiff, Leicestershire, London and Manchester plus a sub office in Wakefield. Commissioners are regionally based and supported by independent investigators, as well as case workers and specialist support staff.
  • The IPCC web site is constantly updated at or members of the public can contact the IPCC on 08453 002 002.

For further information please contact:

Rachael Collins, IPCC Press Officer on 020 7166 3142 or the out-of-hours duty press officer on 07717 851157.A

Thursday, March 18, 1999 Published at 13:32 GMT

Police on mental health frontline

New measures to ensure the mentally ill take their medication could mean a big increase in the role police play in community care, say police and mental health workers.

The City of London police and the National Schizophrenia Fellowship (NSF) are meeting on Thursday to raise awareness among police officers of mental health issues.

Both believe the proposed introduction of community treatment orders for the mentally ill who are released from hospital will increase police work with vulnerable patients.

A spokesman for the NSF said: "Because of failings in the community care system, police have been thrust into the frontline.

"They are the only service which can be relied upon to get to a scene within minutes and can be called out 24 hours a day.

"With the community treatment orders, police may be involved more closely so it is very important for us to get the relationship right."

He added that police may be required to escort people to clinics if they fail to take their drugs, as required by the new orders.


Sergeant Tim Parsons of the City of London Police agreed that the orders were likely to increase police work with the mentally ill.

He said this had been rising ever since the introduction of community care legislation.

The City of London Police has just set up a database to record how police deal with the mentally ill in custody.

Sgt Parsons said this would help show the extent of police work with the mentally ill as well as improving ways of dealing with vulnerable people.

He added that police training in the past had concentrated on mental health legislation and was now moving towards the practicalities of dealing with the mentally ill.

The NSF wants more court diversion schemes to be set up around the country to divert the mentally ill out of the criminal justice system and into social services.

The police agree that prison is not the best place to deal with the mentally ill.

Response units

Sir Paul Condon, head of the Metropolitan Police, has said he is increasingly concerned that police officers are being expected to do the job of mental health workers.

Senior officers are looking at how the police should deal with vulnerable people like the mentally ill.

This could include the setting-up of response units of police and health workers to be sent out to calls which involve mentally ill people.

Thursday's conference is part of ongoing efforts by mental health charities and the police to improve the way officers treat the mentally ill.

Over the last few years, the NSF has been holding conferences with police units around the country, including the British Transport police, the Metropolitan police and Greater Manchester police.

It has also held meetings with the Association of Chief Police Officers.

A spokesman said the response from police had been good.