Prevention of Future Deaths reports · 2017

Jason Basalat

Regulation 28 report to prevent future deaths, reference 2017-0423, written 27 Nov 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Nov 2017
Reference2017-0423
DeceasedJason Basalat
CoronerThomas Osborne
Coroner areaMilton Keynes
CategoryState Custody related deaths
Organisation namedNorthamptonshire Healthcare NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

HM Senior Coroner
for Milton Keynes

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:
The Chief Constable, Northamptonshire Police
The Clerk to Northamptonshire Magistrates Courts

CORONER THOMAS R OSBORNE

| am Thomas Ralph Osborne, HM Senior Coroner for Milton Keynes.

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 12/12/2016 | commenced an investigation into the death of Mr Jason Basalat, aged 52. The
investigation concluded at the end of the inquest on Friday 17™ November 2017. The conclusion
of the inquest was as set out in the narrative questionnaire completed by the jury, a copy of
which is attached.

CIRCUMSTANCES OF THE DEATH
Mr Basalat was arrested on 09/12/16 for an assault after he had grabbed the steering wheel of a
coach/bus he was a passenger on and forced it to crash into the central barriers.

The witnesses describe his behaviour as being strange. He was charged and remanded by
Northamptonshire Magistrates Court. The reason that bail was refused was for his own
protection.

He arrived at HUP WOODHILL at approximately 1430 on Saturday 10/12/16. He refused to
engage with prison staff during the interview stage and notes state that there were no indications
of self harm.

At 07:15 hours 11/12/2016 he was seen in his cell by prison officers and appeared fine. At 08:05
11/12/2016 he was found hanging from a bed frame with a blanket as a noose in his cell, CPR
was commenced and he was taken to Milton Keynes Hospital where his death was confirmed.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) The deceased had been arrested for Dangerous Driving when, on the 9" December
2016, he tried to grab the steering wheel of bus travelling on the M1 motorway forcing it
to collide with the barriers in the roadworks. Whilst in police custody the deceased was
behaving in a bizarre manner and was assessed by a medical practitioner at the custody
centre. When eventually transferred to Woodhill Prison after appearing on a Saturday
Morning at Wellingborough Magistrates Court the warrant simply stated that the offence

(2

(3

LY

~

was “Dangerous Driving.” Which did not in any way give a true picture of the offence and
very little information was provided to the prison as to his behaviour or mental state. The
prison informed me that it would have been helpful for them to receive a copy of the
deceased’s custody record that gave the full picture.

When the deceased appeared before the magistrates his solicitor was informed that it
was not possible on a Saturday morning for a mental health assessment to be
conducted. The court did not attempt to contact the prison to inform the prison of the
problems being experienced by him due to his mental illness. Consideration should have
been given as to the most appropriate place for the deceased to be held or to receive a
mental health assessment.

There needs to be an urgent review by both the Northamptonshire Police and the
Northamptonshire Magistrates Court as to their procedures for sharing information with
the prison when it is known in advance that the prison will receive a vulnerable prisoner.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the power
to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by
20m January 2018. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons
e HMP Woodhill
e Central and North West London NHS Trust
e The family of the deceased

| have also sent it to Prison Ombudsman who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He

Signature__ ot "NS
for Milton Keynes

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Northampton Police (PDF)
In the Matter of the Death of Mr Jason Basalat
Response of the Chief Constable of Northamptonshire Police pursuant to

Regulation 29 of the Coroners (Investigations) Rules 2013

1 Preamble

1.1

1.2

1.3

1.4

The Chief Constable makes this response to the Coroner’s Report dated the 27" November
2017 and issued under the provisions of Regulation 28 of the Coroners (Investigations) Rules
2013.

The original date for providing a response was the 22™ January 2018, but this date was
extended by HM Coroner to the 6" April 2018 to allow the Chief Constable to receive copies
of the documents and evidence considered by the Inquest and also recordings of the Inquest
proceedings, no transcript being available.

The Chief Constable in making this response notwithstanding:

1.3.1 _ the surprising decision of the Coroner, in the context of an Article 2 inquest into the
death of Mr Basalat while in the custody of the State and two days after he had
been in the custody of the police, not to give formal notice to the Chief Constable as
a properly interested person as required by Regulation 20 (2) (h) of the Coroners
Rules 1984 at the commencement of the Coroner’s investigations; or

1.3.2 thereafter, not to give such notice when the issue of events in and flowing from
police custody were raised at the Pre Inquest Review on the 20" June 2017 by
Counsel for the family; or

1.3.3. thereafter, when the issue was specifically raised by Counsel for the Prison Service
on the first day of the Inquest hearing; or

1.3.4 thereafter, when the Coroner himself identified, during questioning of the only
police witness called by the Coroner to give evidence on the first day of the Inquest
hearing, that he was not competent to deal with all the areas of questioning posed
by Counsel for the family, specifically as to police custody practice and procedure;
or

1.3.5 in any event at the point when the Coroner decided that the inquest jury should
be specifically asked to consider whether the actions or omissions of
Northamptonshire Police had caused or contributed to the cause of death.

The Chief Constable has considered his position and taken the view that he will not
challenge the findings of the inquest on the basis that this would, in all likelihood, result in a
requirement for a further inquest to be held and that this would be unfair to the family of
Mr Basalat.

1.5

Accordingly, the Chief Constable responds to the report as follows, but has also, where
necessary, makes reference to matters which do not appear to have been made known to or

considered by the Inquest hearing.

2 Terms of Response Required

2.1

In accordance with the terms of the Report issued by the Coroner, this response addresses

the following areas of concern:

2.1.1

2.1.2

2.1.3

3 Background

311,

Arrest

31.1

3.1.2

3.1.3

“(1) The deceased had been arrested for Dangerous Driving when, on the 9”
December 2016, he tried to grab the steering wheel of bus travelling on the M1
motorway forcing it to collide with the barriers in the roadworks. Whilst in police
custody the deceased was behaving in a bizarre manner and was assessed by a
medical practitioner at the custody centre. When eventually transferred to
Woodhill Prison after appearing on a Saturday Morning at Wellingborough
Magistrates Court the warrant simply stated that the offence was “Dangerous
Driving”. Which did not in any way give a true picture of the offence and very
little information was provided to the prison as to his behaviour or his mental state.
The prison informed me that it would have been helpful for them to receive a
copy of the deceased’s custody record that gave the full picture.”

Point (2) appears to relate solely to the procedure before the Magistrates’ Court and
is not addressed in this response.

“(3) There needs to be an urgent review by both the Northamptonshire Police and
the Northamptonshire Magistrates’ Court as to their procedures for sharing
information with the prison when it is known in advance that the prison will receive
a vulnerable prisoner.”

Mr Basalat was arrested on the 9" December 2016, following a report to the police
that a coach had crashed on the M1 motorway. Officers attended and were told that
Mr Basalat had seized the steering wheel of the coach and turned it towards a
temporary barrier, causing it to collide.

Witnesses on the coach told the police that, prior to the incident, Mr Basalat had
been talking to himself.

Mr Basalat was arrested on suspicion of having committed an offence of common
assault on the coach driver.

3.2

3.1.4 Mr Basalat was conveyed to the custody suite at the Northampton Criminal Justice
Centre.

Detention
3.2.1 Mr Basalat arrived at the custody suite at 06.35 hours on the 9" December 2016.

3.2.2 His detention was authorised at 07.07 by Sergeant mz The circumstances of
arrest given to Sergeant EE are stated as: ‘DP [i.e Detained Person] was
travelling on a National Express Coach on the M1 when he approached the driver,
grabbed hold of the steering wheel, pushed it to the left forcing the coach to collide
with the barrier bringing the coach to a stop’. Detention was authorised for the
purposes of securing and preserving evidence by questioning.

3.2.3 Sergean {El conducted a risk assessment of Mr Basalat at 07.13. The risk
assessment involved firstly asking Mr Basalat a set of pre-determined questions (the
Inquest had before it a copy of the custody questions and they are not repeated
here). In answer to the questions, Mr Basalat confirmed the following:

3.2.3.1 he hit his head hard in the accident that morning;
3.2.3.2 he was prescribed alanzapine and diloxatine but had none with him;

3.2.2.3 he suffered from paranoid schizophrenia and was supposed to be
medicated, that he came out of hospital yesterday — Edinburgh main
hospital for mental health;

3.2.3.4 he had tried to harm himself lots of times, the last occasion a year ago when
he head butted a wall and that he did not feel good at the moment;

3.2.3.5 he was alcohol dependent and hallucinates when he had not had a drink,
the last occasion being 5 days previously;

3.2.3.6 he needed to see a doctor and that it had been difficult for him to get out of
the hospital and he had not told them the truth.

3.2.4 Asaresult of that process, Sergeant Pateman arranged for a Healthcare Professional
to examine Mr Basalat.

3.2.5 At 07.24, Sergeant a :: a result of the risk assessment, determined that Mr
Basalat’s risk to himself should be viewed as medium. He was placed in a CCTV
monitored cell and was to be visited every 30 minutes and roused, because of
concerns about his head injury. This regime was to remain in place until he was

seen by a Healthcare Professional.

3.2.6 At 07.25, Mr Basalat’s property and any item of clothing which might be used to self
harm was removed from him.

3.2.7. At 07.50, Sergeant MEE spoke to the Healthcare Professional, in

relation to Mr Basalat.

22

3.2.9

3.2:10

3.2.11

At 09.07, Community Psychiatric Nurse Day examined Mr Basalt in a
consultation which lasted 28 minutes. She noted the following: “Alert, able to
mobilise, speech spontaneous, coherent, normal rate, tone and volume. Engaged
well in conversation, thought process was fluid and easy to follow, content remained
within context. No evidence of being distracted by or responding to unknown
stimuli. No psychomotor agitation or impairment. Reported hearing and speaking
to people but no evidence of this. Denied alcohol/substance use, denied taking
medication.”

Community Psychiatric Nursel oay also made contact with the practice in
Edinburgh where Mr Basalat had been treated the following day and noted the
following at 11.29: “Discussed with Edinburgh Access Practice and the CPN attached
to the homeless team who the DP is open to. Diagnosed with dissocial personality
disorder. Assessed under MHA assessment last night, no psychotic features, no
suicidal tendencies, deemed fit to return to hostel and engage with CPN. Diagnosis
of Pulmonary Embolism confirmed.”

Nurse Day confirmed that Mr Basalat was fit to detain and fit to be interviewed.

Mr Basalat was interviewed under caution » Mr Basalat was
represented by a solicitor and an appropriate adult. Mr Basalat was additionally
arrested for the offences of Criminal Damage with intent to endanger life and
Dangerous Driving. Mr Basalat gave a pre-prepared statement. At 17.35 Mr Basalat
returned from interview.

3.2.12 HE sv pmittea a request to the Crown Prosecution Service for charging

advice and the charge of Dangerous Driving was authorised. Mr Basalat was charged
with the offence at 21.50. The form of the charge wording is prescribed.

3.2.13. Mr Basalat’s further detention was authorised for him to appear before a remand
court.

3.2.14 Throughout the period of his police detention, the detention was appropriately
reviewed under the provisions of the Police and Criminal Evidence Act 1984 and
Code of Practice C for the detention, treatment and questioning persons by police
officers.

Transfer

3.3.1 Mr Basalat was released in to the custody of Geo Amey at 08.38 on the 10"
December 2016.

3.3.2 In accordance with the Authorised Professional Practice promulgated by the College
of Policing, a Person Escort Form was completed 22.17 on the 9"
December 2016.

3.3.3. The section of the form headed ‘Current and Relevant Risk’ was not completed.

3.4

3.3.4 The section of the form headed ‘Health Risks’ contained the following information
under heading of ‘Details of Current & Relevant Risk’:

3.3.4.1 “Medication — Alanzapine and Diloxatine”
3.3.4.2 “Hit Head in Accident 09/12/2016”;
3.3.4.3 “Alcoholic”;
3.3.4.4 “Paranoid Schizophrenia”; and
3.3.4.5 “S/Harms”.

Police National Computer

A check of the Police National Computer has shown that there were no warning markers to
indicate that he had previously been considered to be at risk of self harm.

4 Response

4.1

4.2

4.3

44

As to: “(1) The deceased had been arrested for Dangerous Driving when, on the 9"
December 2016, he tried to grab the steering wheel of bus travelling on the M1
motorway forcing it to collide with the barriers in the roadworks. Whilst in police
custody the deceased was behaving in a bizarre manner and was assessed by a
medical practitioner at the custody centre. When eventually transferred to
Woodhill Prison after appearing on a Saturday Morning at Wellingborough
Magistrates Court the warrant simply stated that the offence was “Dangerous
Driving”. Which did not in any way give a true picture of the offence and very
little information was provided to the prison as to his behaviour or his mental state.
The prison informed me that it would have been helpful for them to receive a
copy of the deceased’s custody record that gave the full picture.”

As this particular concern appears to be made up of a number of discrete issues, they have
been dealt with as separate matters as follows below, to avoid confusion.

The format of the charge of Dangerous Driving is prescribed by a national code to ensure a
consistency of approach. The purpose of a charge is to provide an accused person with
sufficient information about the nature of the charge laid against them to enable them to
determine whether or not to admit or deny guilt. It will not contain a narrative or summary
of the evidence supporting the charge; that information falls to be disclosed in the course of
any subsequent proceedings.

The standard offence wording for an offence of Dangerous Driving is as follows:

On **(..SPECIFY DATE..) at **(..SPECIFY TOWNSHIP..) drove a mechanically propelled vehicle,
namely **(..SPECIFY VEHICLE MAKE AND INDEX NUMBER..) dangerously on

(A)_[a road,]_

(B)_[roads,]_

4.5

4.6

47

4.8

4.9

4.10

4.11

4.12

4.13

4.14

(C)_[a public place,]_
namely **(..SPECIFY ROAD/ROADS/PLACE/PLACES..)

Accordingly, the terms of the charge laid in Mr Basalat’s case was in accordance with the
national standard.

The format of the Warrant of Remand is not a matter for the police and the Chief Constable
makes no comment on that issue.

The Custody Record is a document which the police are required to maintain to record
certain decisions made pursuant to section 37 of the Police and Criminal Evidence Act 1984
and paragraph 2.1 of Code of Practice C referred to above.

Paragraph 2.3 of the Code of Practice states as follows:

“2.3 The custody officer is responsible for the custody record's accuracy and completeness
and for making sure the record or copy of the record accompanies a detainee if they are
transferred to another police station. The record shall show the:

time and reason for transfer;
time a person is released from detention. “ (emphasis added)

The purpose of a Custody Record is not to record information in relation to the course of a
criminal investigation or the evidence gathered; it is a record of the treatment of a detained
person while in police custody. It will not, therefore, give a ‘full’ picture.

Custody records are electronic documents. They are not ordinarily printed out to accompany
a detained person on transfer to court. This is so even when there is to be an application for
a remand into custody. However, see below at paragraphs 4.14 et seq in relation to the
guidance set out in the College of Policing’s Authorised Professional Practice.

As to: “(3) There needs to be an urgent review by both the Northamptonshire Police and
the Northamptonshire Magistrates’ Court as to their procedures for sharing
information with the prison when it is known in advance that the prison will receive

a vulnerable prisoner.”

Following receipt of the Coroner’s Report, a review of the circumstances of Mr Basalat’s case
was conducted and considered against existing procedures. Following the provision of the
witness and documentary evidence referred to in the Inquest Hearing, that review was
revisited to ascertain whether any additional matters required scrutiny.

Northamptonshire Police adopts the College of Policing Authorised Professional Practice for
Detention and Custody. All custody staff are trained in accordance with it and are able to
access it online in the event of query. A copy of the section on Risk Assessment is appended
to this response.

Within the section on Risk Assessment, guidance is given in relation to the use of the Person
Escort Form as follows:

4.15

“Person escort record form

The PER form provides staff transporting and receiving detainees with all necessary
information. This includes any risks or vulnerabilities that the person may present.

Officers must complete a PER form whenever a detainee is escorted from a police station to
another location. This includes movement or transfer between separate custody suites
(police stations) and other custody accommodation (courts, prisons and immigration
detention facilities) and from custody to hospital.

Identifying a risk of suicide or self-harm is one of the prime purposes of the form. Staff must
indicate both a current risk and any known past risks.

PER form requirements

Where the detainee is to be transferred from a police station, the responsibility for the PER
form lies with the first custody officer who becomes aware of the transfer.

The form may be completed by a trained and competent custody detention

officer, but responsibility for the form content and sign off remains with the custody officer.
This reduces the risk of important information being lost during any subsequent handovers
between custody officers.

It is the responsibility of the custody officer who transfers the detainee from the police
station to the escort to ensure that the PER is up to date and contains details of any
additional post-charge or other care requirements.

Custody officers must provide supporting information when ticking a warning marker box.

Officers should attach copies of risk assessment forms and medical examination records that
are not confidential to the PER. They should also enter relevant information onto the PER in
case any of the attached information is lost. Confidential medical information must be
attached in a sealed envelope. Information relating to self-harm or suicide cannot be
deemed confidential and should always be on the PER form.

Staff should add a direct contact telephone number for the custody suite to the PER so that
escort, court, probation or prison staff can make prompt contact with the custody officer
should they need to clarify any information.

The escorting staff are responsible for maintaining a record of the detainee’s movements
and any occurrences during transit.”

In this case, the content of the PER form is brief, but nonetheless lists the significant risk
factors which had been identified during Mr Basalat’s time in police custody. Medical
examination and information from his treating practice had not raised concerns of self harm.
Although no direct telephone number was provided for the custody suite, it was one of only
two in Northamptonshire and Northamptonshire Police operates a 24 hour, 7 day per week
switchboard through which any enquiries could have been directed.

4.16

4.17

However, the Chief Constable confirms that Custody officers and staff have been reminded
of the guidance in relation to the completion of PER forms and in respect of ensuring any
relevant additional documentation accompanies them.

Further, contact will be made with the national police lead on Custody to suggest a review of
the PER form to ensure it reflects the guidance in the Authorised Professional Practice.
Response from Respondent Not Named (PDF)
NORTHAMPTONSHIRE MAGISTRATES’ COURTS RESPONSE TO HM

CORONER’S REGULATION 28 REPORT TO PREVENT FUTURE DEATHS —
RE: MR JASON BASALAT

INTRODUCTION

ae

On 27" November, 2017 Mr Osbourne, HM Senior Coroner for Milton Keynes, requested a
response from the Clerk to the Northamptonshire Magistrates’ Court to his report to prevent
future deaths made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 (the Act)
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 arising from the death
of Mr Jason Basalat.

Her Majesty’s Courts and Tribunals Service wish to place on record its concern that it was not
identified as an interested party in accordance with Section 47 (1) (2) (f) or (m) of the Act or
required to give or submit any evidence to the inquest into the death of Mr Basalat, in accordance
with Section 32 and Paragraph 1 of Schedule 5 of the Act. This concern relates particularly to the
first question put to the inquest jury that the courts service had failed to Pass on information
regarding the offence and concerns relating to Mr Basalat to the prison authorities and that that

failure caused or contributed to his death.

BACKGROUND

3.

Mr Basalat appeared in custody before the Northamptonshire Magistrates’ Court sitting at
Wellingborough on 10" December, 2016, a Saturday morning, charged with an allegation that on
9" December, 2016 he had driven a National Express coach on the M1 dangerously contrary to
section 2 of the Road Traffic Act 1988, BE appeared on behalf of the Crown Prosecution
Service and a Nobles Solicitors, represented Mr Basalat. The legal adviser to the
magistrates was

Brief details of the offence were outlined to the court, who were also advised that, in respect of
Mr Basalat’s mental health, the all clear had been given by the police’s doctor/mental health team.
There were no concerns about Mr Basalat from the Community Psychiatric Nurse who had
assessed him in custody the previous evening so a CPN1 was not completed.

The court determined that the matter was too serious to be heard in the magistrates’ court and

sent the matter to Northampton Crown Court for trial; Mr Basalat not having indicated a plea.

There was no application for bail and Mr Basalat was remanded in custody to appear before the
Crown Court. The exceptions stated for refusing bail were that, Mr Basalat may failure to
surrender to custody and may commit further offences on the grounds of the nature and
seriousness of the charge, not for his own protection as stated in the Coroner’s report (see copy

record of bail decision appendix A).

2. PY not knowing that Mr Basalat had been seen the previous evening by a CPN, tried to

10.
11.
12.

13.

14.

contact the CPN service but was not successful. The remand warrant authorising Mr Basalat’s
detention was issued to GeoAmey, the prisoner escort sevice nn put a marker on the
warrant indicating the prosecution’s and defence’s representations regarding Mr Basalat’s mental
health.

A Person Escort Record form had been completed by the police and would have accompanied Mr
Basalat.

Subsequently, Mr Basalat was taken to HMP Woodhill where on 11" December, 2016 he was
found hanging from his bed frame, he was taken to Milton Keynes hospital where his death was

confirmed.

CORONER’S CONCERNS

Matters of Concern

“The warrant simply stated that the offence was “Dangerous Driving”. Which did not in any way
give a true picture of the offence and very little information was provided to the prison as to his

behaviour or mental state.”

On a normal working day, any remand warrant would generally be generated by the court’s
computer system when the result is entered. This would state the full charge which would detail
the date, place etc. of the offence; however, it would not outline how the offence was alleged to
have been committed. At present, on a Saturday, as there are no support staff, the lega! adviser
manually generates the warrant and records only a brief description of the offence. This is normal
practice; full details of the charge, in any event as stated above, would not indicate the

circumstances of the offence or any behaviour or mental health issues.

HMCTS is implementing an ‘in-court’ computer system which requires the legal adviser, rather
than support staff, to enter the court result. This will generate a warrant with the full charge but

will not include the circumstances of the offence.

mC did place a marker on the warrant in relation to Mr Basalat’s mental health,

unfortunately, although the legal adviser’s contemporaneous notes, state; “marker put on
remand warrant for GeoAmy re: pros & def rep’s re m health” MMis unable, given the
passage of time, to recall the details of that note. A copy of the warrant has been requested from

the Coroner’s office but this has not been forthcoming.

+ 7 again as evidenced by her notes, did try and call in the Community Psychiatric Nurse

17.

18.

79.

20.

21,

Service to no avail. If she had been successful then the CPN’s assessment, recorded on form CPN1
would have been available to forward to the prison with the warrant. In any event a CPN had
assessed Mr Basalat the previous evening and had not completed a CPN1 because they had no

concerns.

The court did have in its possession a physical copy of the police form MGS5 which includes an
outline of the circumstances of the offence by way of a summary of the evidence supported by
the key statements. It is not normal practice for this to be forwarded to the prison, consideration

will be given at to whether it should be in the future — see below.

“The prison informed me that it would have been helpful for them to receive a copy of the

deceased’s custody record that gave the full picture.”

This was not in the possession of the court and would not normally be. The police had completed

a PER form.

“When the deceased appeared before the magistrates his solicitor was informed that it was not

possible on a Saturday morning for a mental health assessment to be conducted.”

The court does have in place a process to provide it with information when vulnerable adults are
detained in custody. This is initiated by the police when they have concerns that such an adult is
being detained; they will request a CPN to attend the custody suite and carry out an assessment.
The assessment is then recorded on form CPN1 and this is then forwarded to the court when the
defendant appears before them in custody, or at a later date if the defendant is released to appear

on a subsequent occasion.

22.

233

24.

25%

26.

27.

28.

29.

30.

31.

If the court believes a vulnerable adult is appearing before them without such an assessment
having been carried out then there is a call-in scheme for a CPN to attend and complete an

assessment and submit a report, again on a CPN1.

On this occasion, even though a Saturday morning, it should have been possible to contact a CPN
to attend and carry out an assessment. Unfortunately, as stated above Ms Mehan was

unsuccessful in her attempts to do so.

In any event, on this occasion, the court was advised that Mr Basalat had been given the all clear
by the police doctor/mental health team to attend court. There were no concerns about Mr

Basalat from the Community Psychiatric Nurse who had assessed him in custody.

Ms Mehan does not recall that Mr Basalat’s solicitor requested that a CPN attend.

“The court did not attempt to contact the prison to inform the prison of the problems being

experienced by him due to his mental illness.”

Ms Mehan did place a marker on the warrant indicating that Mr Basalat had mental health issues.

Without sight of the warrant it is not possible to comment on the details of that marker.

It is not normal practice for a legal adviser to directly contact any prison establishment. Unlike any
custodian of a detained person the court does not undertake a risk assessment of a prisoner. The

police had completed a Person Escort Record form and this would have accompanied Mr Basalat.

“Consideration should have been given as to the most appropriate place for the deceased to be

held or to receive a mental health assessment.”

No representations were made from either party that Mr Basalat should be remanded to any
establishment other than a penal one. The court had been specifically advised that Mr Basalat had

been given the all clear to appear before the court by the police doctor/mental health team.

The court does have power, under certain circumstances, to remand a defendant to a hospital or
custodial establishment for a mental health assessment if it is satisfied that the defendant did the

act or omission alleged, however, in this case the defendant had not indicated a plea and had been

SUMMARY AND WAY FORWARD

38. HMCTS is concerned that it was not identified as an interested party or requested to submit any

39.

40.

41.

42.

43.

44.

evidence or make any representations to the inquest into the death of Mr Basalat.
There has been a review of Mr Basalat’s appearance before the court on 10" December 2016, This
concluded that:

a) Mr Basalat was sent to the Crown Court for trial and he was remanded in custody on
the grounds that he would fail to surrender to custody and commit further offences.

b) Mr Basalat had been cleared to attend court by the police’s doctor/mental health
team. A CPN had assessed Mr Basalat the previous evening.

c) There was no CPN1 available and a. attempt to call in a CPN was
unsuccessful.

d) The warrant issued by was endorsed indicating that Mr Basalat had mental
health difficulties. The warrant only detailed the offence as ‘dangerous driving’ and
no further information was Provided; the court did have in its possession an MGS.

e) No representations were made to the court that Mr Basalat should be remanded to
any other establishment other that the usual remand prison.

The court does have in place procedures to ensure vulnerable adults are identified and
assessments undertaken.
Liaison has taken place with Northamptonshire Constabulary and Northamptonshire PCC’s office
and this has established;

a) The police are undertaking their own review and further liaison will take place
following its conclusion.

b) The PCC’s office is re-negotiating a new contract for the provision of healthcare in
custody.

The court will liaise with the Criminal Justice Liaison and Diversion Team, to review the robustness
of the present CPN Procedures and consider what further information should be forwarded toa
prison should a vulnerable adult be remanded to it.

Legal advisers have been issued with the above Team’s information leaflet and reminded of the
need to forward the CPN1 form to the relevant custodial establishment if a vulnerable adult is
remanded into custody. Failing this, to endorse the warrant and forward the MGS, if available.

If a report on the outcomes of future liaison with the police/PCC/Criminal Justice Liaison and
Diversion Team are required, then the court respectively requests an extension of the period
allowed for this response. (It is understood that Northamptonshire Constabulary will be

requesting an extension of six weeks and if granted a similar time-period is likewise requested.)

Bz.

sent to the Crown Court for trial. Additionally, the court was not in a position to conduct such an

enquiry and had not been invited to do so by either party.

A copy of the record of the proceedings, including Ms Mehan’s notes, see appendix B and

statement made by Ms Mehan, see appendix C are attached.

PROCEDURES IN PLACE, ACTION TAKEN AND TO BE TAKEN

33.

34.

35:

36.

37.

As outline above the court does have procedures in place to ensure that vulnerable defendants
are identified to the court; see appendix D and E. Magistrates have been made aware of these
procedures, see appendix F and training has been delivered to magistrates and evaluated, see

appendix G.

Following receipt of the Coroner’s report liaison has taken place with the relevant criminal justice
agencies. The court is aware that Northampton Constabulary are conducting its own review, which
will include the CPN response. Following its conclusion there will be further liaison to share
outcomes and ensure that the necessary information is shared with the prison when a vulner.vle

adult is remanded into their care.

The court is also aware that the Northamptonshire Police and Crime Commissioner's office is re-
negotiating a new contract for the provision of healthcare in custody. Again, there will be further

liaison following this review.

The court facilitates a ‘custody meeting’ attended by numerous criminal justice agencies. This
group has in the past overseen the CPN procedure. The court will liaise with the Criminal Justice
Liaison and Diversion Team, Northamptonshire Healthcare NHS Foundation Trust to review the
robustness of the present procedures and to consider what further information should be

forwarded to a prison should a vulnerable adult be remanded to it.

In the interim, legal advisers have been issued with the above Team’s information leaflet, see
appendix H, and reminded of the need to forward the CPN1 form to the relevant custodial
establishment if a vulnerable adult is remanded into custody. They have also been advised that if
a CPN1 form is not available then they should ensure that any warrant is suitably endorsed and if

available the MG5 should accompany the warrant.

Deputy Clerk to the Justices

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