Gurdeep Singh Dundhal

Dr Fiona Reynolds 
Chief Medical Officer 
Executive Team 
Birmingham Women’s and Children’s NHSFT 
Steelhouse Lane 
Birmingham 
B4 6NH 

www.bwc.nhs.uk 

Mrs Louise Hunt 
Senior Coroner for Birmingham and Solihull 
50 Newton Street 
Birmingham 
B4 6NE 

1 November 2019 

Dear Mrs Hunt  

Re: Gurdeep Dundhal; Regulation 28 Report to Prevent Future Deaths 

I write in response to your Regulation 28 Report issued to Birmingham Women’s and Children’s 
NHS  Foundation  Trust,  Walsall  Metropolitan  Borough  Council,  Birmingham  City  Council  and 
Priory Group of Hospitals on 10 September 2019, following the inquest into the tragic death of 
Gurdeep Dundhal.  

We would like to express our sincere condolences to the family of Gurdeep, who sadly have lost 
a very special young man.  

The matters of concern you raised in your Report are as follows;  

“There  was  a  delay  in  organising  the  assessment  of  Mr  Dundhal  when  he  was  detained  on 
S5(2)  of  the  Mental  Health  Act  on  11/04/19.  The  evidence  confirmed  there  appeared  to  be 
confusion as to who was to undertake the assessment between Walsall MBC and Birmingham 
City Council. In addition there was a lack of resources to enable the assessment to be carried 
out in a timely manner. This meant the assessment was carried out just a few hours before the 
time period for the S5(2) was to expire.  

Evidence  at  the  inquest  from  the  approved  Mental  health  practitioner  confirmed  that  key 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 information and documentation were either unavailable and/or not asked for during the mental 
health  act  assessment  on  14/04/19.  I was unable  to  confirm  which  at  the  inquest.  This meant 
the  true  nature  of  Mr  Dundhal’s  long  term  condition  was  not  known  and  the  assessors  were 
unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack 
of available information.  

When  Mr  Dundhal  was  admitted  to  hospital  on  15/03/19  he  was  placed  on  S2  of  the  Mental 
Health  Act  when  his  clinical  team  had  specifically  recommended  he  be  placed  on  S3.  No 
explanation was available for this. Evidence at the inquest suggested this was a decision made 
by the Approved Mental health practitioner from Birmingham City Council. Consideration needs 
to given as to why a S3 was not put in place in accordance with the recommendation.  

Walsall  MBC  has  failed  to  undertake  an  internal  investigation  into  the  delays  and  resources 
concerns  during  the  assessment  in  April  19.  They  have  also  failed  to  engage  with  other 
agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies 
work together after a tragedy to ensure lessons are learnt to protect others.” 

In  preparing  this  response,  we  have  obtained  the  call  logs  from  14  April  2019,  providing  the 
telephone  numbers  which  called  in  to  the  Access  Centre  on  that  day.  We  were  concerned  to 
hear at the inquest that the request for Mr Dundhal’s records was made and not complied with. 
Unfortunately,  we  have  not  been  able  to  establish  the  telephone  number  which  the  Approved 
Mental Health Practitioner called from and as such we are limited in our investigations on this 
point. 

We  understood  from  the  evidence  provided  at  the  inquest  that  the  Approved  Mental  Health 
Practitioner  made  a  call  to  the  Access  Centre  on  14  April  2019  in  order  to  make  attempts  to 
obtain Mr Dundhal’s records held by FTB. Whilst it is the case that the Access Centre is closed 
at  weekends,  I  can  confirm  that  calls  made  to  this  number  out  of  hours  are  routed  to  FTB’s 
urgent  care  team.  Therefore  any  call  made  to  the  Access  Centre  would  have  been  picked  up 
by the  shift  coordinator  in  the  adult  crisis  team.  All  calls  to  this  number  are  recorded  as  a 
relevant  clinical  record.  All  calls  that  came  through  the  Access  line  to  urgent  care  on  14  April 
2019 have been reviewed and we have not been able to identify the call on our audio file.  

I  would  like  to  reassure  you,  however,  that  FTB  records  are  held  electronically  and  these  are 
easily  available  to  be  shared  where  appropriate.  Although  we  are  unable  to  establish  the 
precise  circumstances  of  this  call,  as  a  direct  result  of  your  report,  we  have  redistributed  the 
safer  inter  agency  information  sharing  guidance  within  the  urgent  care  team  and  at  the  local 
governance meetings to ensure that any lessons to be learnt are implemented.  

Since the issue of your Report, we have been contacted by Walsall MBC and have been invited 
to participate in a multi agency meeting to discuss this matter. We await a date for the meeting, 
following  which  further  actions  may  become  apparent.  I  will  write  to  you  again  to  provide  the 
details of the outcome of this meeting.  

I hope this letter serves to reassure you that the concerns you raised have been acted upon.  

 
 
 
 
 
 
 
 
 
 
 We will continue to engage with other agencies to enable the Trust to learn from incidents and 
improve patient care.  

Yours sincerely 

Dr Fiona Reynolds 
Chief Medical Officer 
Birmingham Women’s and Children’s NHSFT

PRIORY

Director of Risk Management
Priory Group

Fifth floor

80 Hammersmith Road
London, W14 8UD

Monday 4 November 2019

Ms Louise Hunt

HM Senior Coroner for Birmingham & Solihull
Coroner's Court

50 Newton Street

Birmingham, B4 6NE

By email: coroner@birmingham.gov.uk

Dear Ma’am

Re. Mr Gurdeep Dundhal (deceased)

I write to you in response to the Regulation 28 Prevention of Future Deaths Report dated Tuesday 10
September 2019 that you issued following the Inquest touching the death of Mr Gurdeep Dundhal.
We note that your report was addressed to Walsall MBC, Birmingham City Council, Birmingham
Women’s and Children’s NHS Foundation Trust and the Priory Group of Hospitals (PGH).

You will appreciate that in respect of points 1, 3 and 4, PGH is not in a position to comment and that
(i) any delays in arranging the MHA assessment; (ii) the use of Section 2 rather than a Section 3
detention on admission; and (iii) the failure by Walsall MBC to undertake an investigation are matters
for the other interested persons noted above to address.

In respect of point 2 and the concern in relation to key information being unavailable or not asked
for, please note that clinical staff at Lakeside View have considerable experience in liaising with
professionals undertaking Mental Health Act assessments and have advised that relevant information
relating to Mr Dundhal was made readily available to the assessing team. Additionally, Mr Dundhal’s
responsible clinician, EE, mace himself available on the day of the assessment and in fact was
contacted by ward staff who asked him to speak to the assessing doctor, [| PGH has also
enquired as to whether there was an IT systems outage on Sunday 14 April 2019 at Lakeside View
which may have impacted on the ability to retrieve electronic clinical notes (CareNotes) for the
assessment thereby making them “unavailable” but has found no evidence to suggest the hospital’s
IT systems were not working normally on that day.

Yours sincerely,

Director of Risk Management

WALSALL COUNCIL 
RESPONSE TO REGULATION 28 REPORT 

Walsall Council has carried out an investigation into the events which took place whilst 
Gurdeep Singh Dundhal was detained by reason of s.5 (2) of the Mental Health Act 
1983. The detention took place between 11.50am on Thursday 11 April 2019 and the 
late morning of Sunday 14 April 2019 when a decision was made, after an assessment 
of  him,  that  it  would  not  be  appropriate  for  him  to  be  detained  in  hospital.  That 
investigation was conducted by the Mental Health Team Manager who reported to the 
Head of Community Care Partnerships. The Head of Community Care Partnerships 
has also held meetings with senior staff and the solicitor to the council to carry out a 
review of what had occurred to identify the causes of any shortcomings, and to put 
into place measures to prevent the recurrence of the shortcomings. The review has 
also opened discussions with a partner authority to consider improvements that can 
be made.  

Matters of concern: 

The delay in organising the assessment of Gurdeep Singh Dundhal 

Gurdeep Singh Dundhal was detained under s.5 (2) of the Mental Health Act 1983 at 
11.50am on Thursday 11 April 2019. Walsall Council was not then told of his detention. 
Lakeside View Hospital, where Gurdeep Singh Dundhal was detained, had informed 
Birmingham City Council of his detention. This was not only an understandable move 
but a sensible one. Lakeside View Hospital had been treating Gurdeep Singh Dundhal 
since mid-March 2019. He had been referred there by the Mental Health Team from 
Birmingham  City  Council  who  had  been  providing  his  care  in  the  community  for 
approximately 3 years. As his home authority it was Birmingham City Council which 
was responsible, in March 2019, for arranging his detention under s.2 of the Mental 
Health  Act  1983  for  assessment.  It  was  Birmingham  City  Council  who  knew  about 
Gurdeep  Singh  Dundhal,  both  from  caring  for  him  for  approximately  3  years  and 
because they held his records. He was wholly unknown to Walsall Council.  

In the afternoon of Friday 12 April Lakeside View Hospital telephoned Walsall Council 
to tell it that an assessment of Gurdeep Singh Dundhal had not yet been carried out. 
Lakeside View said that it had requested Birmingham City Council to co-ordinate the 
assessment.  Walsall Council advised Lakeside View to call back if Birmingham City 
Council did not undertake the assessment.  On the 12th April 2019 at 14:15pm 

 (AMHP) was on duty in the AMHP Hub Walsall Council. He received a call from 
 (AMHP, Birmingham City Council) requesting a Walsall AMHP 
to undertake a Mental Health Act assessment of  Birmingham Resident Mr Gurdeep 
Singh Dundhal who was a patient of Lakeside View Hospital (Priory Group) Walsall 
Walsall  Council  said  that  it  did  not  have  sufficient  resources  to  carry  out  the 
assessment. The investigator could find no good reason why this had been said. There 
were at that time three Approved Mental Health Professionals (AMHPs) on duty. They 
were not at that time dealing with any other referral. Nevertheless Birmingham City 
Council agreed to carry out the assessment. This arrangement was reached at 14:51. 

1 

 
 
 
 
 
 
 
 
 
 There was no further contact with Walsall Council for over 24 hours until Saturday 13 
April  2019  at  17:35  when  Lakeside  View  telephoned  the  Emergency  Duty  Team  at 
Walsall Council to explain that the assessment had not yet been carried out. There 
were  further  telephone  conversations  which  led  to  Walsall  Council  speaking  to  an 
AMHP  from  Birmingham  City  Council.  The  AMHP  from  Birmingham  City  Council 
explained  that  there  had  been  a  difficulty  in  carrying  out  the  assessment.  She  was 
provided with the telephone numbers of the psychiatrists in Walsall approved under 
s.12 of the Mental Health Act 1983. A few minutes later at about 18:20 Birmingham 
City Council informed Walsall Council that it would not be completing the assessment, 
even though it had been commenced.  

It was at this point that Walsall Council assumed the responsibility for carrying out the 
assessment. The AMHP on duty knew that Walsall Council had no direct access to 
Gurdeep Singh Dundhal’s records held by Birmingham City Council or by the mental 
health trust in Birmingham. Whilst those records could be obtained there would be a 
significant  delay  before  they  were  available.  He  made  a  decision  that  it  would  be 
unreasonable to carry out an assessment late on a Saturday evening unless it was 
essential  for  it  then  to  be  carried  out.  It  would  be  more  difficult  to  carry  out  an 
assessment late in the evening and the results could be affected by the hour of the 
day  at  which  it  had  been  conducted.  It  was  his  view  that  it  would  be  better  for  the 
assessment to be carried out the next morning.  

,  an  AMHP  employed  by  Walsall 
On  Sunday  14  April  2019 
Council,  was  due  to  come on duty  at  9am. The  AMHP  who  had been  covering  the 
night shift, and who had made the decision to defer the assessment until that morning, 
 shortly before 08:00 to advise him of the need to carry out an 
contacted 
assessment  on  Gurdeep  Singh  Dundhal  and  that  the  time  for  doing  so  expired  at 
11:50. 
  started  work  immediately,  an  hour  before  his  shift  began.  He 
contacted Lakeside View to arrange for the assessment to be carried out. He obtained 
the contact details of Gurdeep Singh Dundhal’s parents, his GP and the names of the 
two  doctors  who  had  provided  the  medical  recommendations  that  Gurdeep  Singh 
Dundhal should be detained.  

 was told that neither of those two doctors could be contacted and that one 
of  the  doctors,  who  had  come  from  Birmingham,  was  unknown  to  Lakeside  View 
Hospital. He was given a small amount of background information. He made enquiries 
of  Birmingham  City  Council’s  Emergency  Duty  Team  to  obtain  information  about 
Gurdeep  Singh  Dundhal. The Emergency  Duty  Team  said  that  they  had  closed  his 
referral and did not have information about him. He was given the telephone number 
to Birmingham and Solihull Mental Health Trust and was told that Oaklands Centre 
was  overseeing  Gurdeep  Singh  Dundhal’s  care.  Contact  was  made  with  the  crisis 
team  of  Birmingham  and  Solihull  Mental  Health  Trust.  Mr  Panesar  asked  for 
information about Gurdeep Singh Dundhal. He was told that all information about him 
had  been  sent  to  Lakeside  View  and  that  no  doctors  from  his  clinical  care  team  or 
Birmingham services were available to talk to him. 
 asked to speak to the 
home treatment doctors, but was told they were not available. In the absence of any 
 contacted the on call s.12 psychiatrist, who 
other doctor being available, 
  to  attend 
was 
Lakeside View with a view to carrying out the assessment. Those arrangements were 
  had  already  spoken  to  Gurdeep  Singh 
relayed  to  Lakeside  View. 

  at  Dorothy  Pattison  Hospital.  He  arranged  for 

2 

 
 
 
 
 Dundhal’s parents over the telephone and obtained information from them about his 
background.  They  were  in  a  position  to  give  this  information  as  Gurdeep  Singh 
Dundhal lived at home with them.  

  arrived  at  Lakeside  View  at  10.30am  where  he  met 

.  They 
interviewed a psychiatric nurse on the ward who had for some while been looking after 
Gurdeep Singh Dundhal. She was able to give a history of him since his admission 
 met other members of staff who provided the 
there on 15 March 2019. 
documents  setting  out  the  medical  recommendations  in  support  of  Gurdeep  Singh 
Dundhal’s detention under s.3 of the Mental Health Act 1983. He was also provided 
with  the  report  written  by  an  AMHP  for  the  same  purpose.  Further  records  were 
requested  from  the  staff,  who  attempted  to  obtain  them.  There  appeared  to  be 
technical  difficulties  in  the  staff  being  able  to  obtain  the  records,  so  further  oral 
information was sought from the staff.  

 in the presence of 

Gurdeep Singh Dundhal was interviewed by 
and 
,  a  support  worker  from  Lakeside  View  Hospital.  After  the 
interview further enquiries were made of the hospital staff and a discussion was held 
’ initial assessment of Gurdeep Singh Dundhal. There was no 
with them of 
objection from them to his preliminary view. They told him that Gurdeep Singh Dundhal 
had been compliant with his care plan and treatment. 
 was then able to speak 
over the telephone to 
, a consultant from Lakeside View Hospital, who had 
been treating Gurdeep Singh Dundhal and recommended he be detained under s.3 of 
 asked for the contact details of 
the Mental Health Act 1983 for treatment. 
, the other doctor who had provided a medical recommendation, but was 
told his contact details were not available. There was then a further conversation with 
the nurse to whom he had spoken to earlier. It was at this point that the assessment 
was concluded.  

Walsall  Council  points  out  that  it  did  not  know  that  Gurdeep  Singh  Dundhal  was  in 
Lakeside View Hospital and needed to be assessed, and could not reasonably have 
been expected to have known that, until after more than 24 hours had elapsed since 
his detention under s. 5 (2) of the Mental Health Act 1983 when it was contacted about 
him. That contact came from Birmingham City Council in a telephone call. During that 
telephone conversation Birmingham City Council agreed to carry out the assessment 
of  Gurdeep  Singh  Dundhal.  Walsall  Council  had  no  cause  for  concern  about  the 
assessment  being  carried  out  until  Saturday  13  April  2019  at  17:35  when  it  was 
contacted by Lakeside View who said that the assessment had still not been carried 
out.  It  was  approximately  45  minutes  later  that  Walsall  Council  assumed  the 
responsibility for assessing Gurdeep Singh Dundhal when Birmingham City Council 
said that it would not be further attending Lakeside View Hospital. As the assessment 
was  unlikely  to  be  able  to  be  carried  out  until  late  that  evening  the  AMHP  on  duty 
decided that it would be preferable, in the interests of the patient, for the assessment 
to be carried out the following morning. He therefore notified the Sunday morning duty 
AMHP  of  the  need  for  an  assessment  to  be  carried  out.  The  Sunday  morning  duty 
AMHP lost no time in making arrangements for, and seeing that, the assessment was 
carried out. The delay in carrying out the assessment whilst it was the responsibility of  
Walsall Council was from 18:20 on Saturday 13 April 2019 until just before 08:00 on 
Sunday 14 April 2019 when the duty AMHP took steps to make arrangements for the 
assessment to take place. That delay was as a result of the considered decision of the 

3 

 
 
 
 
 
 AMHP on duty taking the view that conducting an assessment late in the evening may 
lead  to  disadvantages  to  the  patient.  If  the  assessment  were  to  be  conducted  the 
following morning those disadvantages could be avoided. Until 18:20 on Saturday 13 
April 2019 Birmingham City Council had agreed to carry out the assessment. It was 
not  until  17:35  on  Saturday  13  April  2019  that  Walsall  Council  was  alerted  by  a 
telephone call from Lakeside View to the fact that the assessment had not yet been 
carried out.   

Steps taken to make improvements 

The  staffing  levels  have  been  increased.  There  is  therefore  a  provision  for  a  duty 
AMHP to be able to call for additional staff if they should be needed. In addition to that 
an  on  call  manager  is  now  available  to  provide  assistance.  A  procedure  is  being 
developed which will request all hospitals in Walsall to notify Walsall Council as soon 
as there may be a need for an assessment to be carried out on any patient in their 
hospital, whether or not that patient is ordinarily resident in Walsall.  

A procedure is also being developed to ensure that whenever another authority agrees 
to undertake an assessment of a patient in Walsall that the progress of the assessment 
is  notified  to Walsall  Council  and  that Walsall  Council’s  staff  will  take  action  in  any 
case  in  which  it  appears  that  there  may  be  a  delay  in  the  carrying  out  of  an 
assessment. In addition to that a procedure is being developed for Walsall Council’s 
staff to request information from other authorities and other parts of the NHS whenever 
it appears that a patient may need to be assessed by Walsall Council. This is to avoid 
delays which may be occasioned by the need to wait for information.  

In  addition  to  that  Walsall  Council  has  opened  discussions  with  other  agencies  to 
develop a practice to be adopted whenever a patient from another authority needs to 
be assessed by Walsall Council.  

The obtaining of information 

Walsall Council has no direct access to any records held by other parties. In view of 
the need for confidentiality and the data protection legislation it is unlikely that third 
parties would be in a position to allow Walsall Council direct access to their records. 
At present the only steps which can be taken by Walsall Council to ensure that records 
are available is to see that they are requested at the earliest opportunity. In this case 
it would have been better if the AMHP on duty on the evening of Saturday 13 April 
2019 had, instead of merely requesting the following day’s duty AMHP to carry out the 
assessment, he himself made the requests for the records to be provided. Instructions 
have  therefore  been  given  that  not  only  should  records  be  sought  at  the  earliest 
opportunity, but whenever an assessment is postponed the period of postponement is 
used  for  the  purpose  of  requesting  records  to  be  made  available.  Walsall  Council 
proposes to keep this matter under review. Despite this, Walsall Council has opened 
discussions with a neighbouring authority to see whether records can be more readily 
available.  

4 

 
 
 
 
 
 
 
 
 
 
 
 The admission to hospital on 15 March 2019 

Walsall Council played no part in this admission and did not know of it. It is thus unable 
to assist on this matter. 

Internal investigation by Walsall Council  

Walsall  Council  has  carried  out  an  investigation  led  by  a  Mental  Health  Team 
Manager.  That  investigation  could  not  begin  until  Walsall  Council  had  received 
information about Gurdeep Singh Dundhal’s death. Although there had been earlier 
conversations with other agencies, it was not until the documents were provided by 
the  Coroner’s  officer  on  3  September  2019  that  Walsall  Council  was  sufficiently 
informed about the matter to begin an investigation. Results of the investigation have 
been set out earlier in this document. In addition to the investigation there has been a 
review led by the Head of Community Care Partnerships, who has consulted not only 
within the mental health team but also Legal Services. The review is looking into any 
deficiencies or perceived deficiencies which there may have been in the provision of 
services in April 2019. There has been an increase in AMHPs employed by Walsall 
Council. There have been changes in working practices to avoid the previous practice 
of  an  AMHP  being  on  duty  for 12  hours followed  by  a  period  of  being  on  call  for a 
further period of 12 hours. In addition to that AMHPs will be available on call to assist 
the AMHP on duty whenever that may be needed. There will also be a manager on 
duty or on call, and thus available to provide assistance, at all times of the day and 
night.  Walsall  Council  has  opened  discussions  with  its  neighbouring  authorities  to 
formalise practices of asking neighbouring authorities to carry out reviews within the 
borough of Walsall. There will be a procedure for staff to ensure that the assessment 
has been carried out and completed in good time and for staff to be called on to assist 
if need be. It is intended that Walsall Council should meet regularly with other agencies 
to identify areas where improvements can be made. 

List of abbreviations 

s.12  psychiatrist  –  a  psychiatrist  approved  for  carrying  out  assessments  under  the 
Mental Health Act 1983 

AMHP – Approved Mental Health Professional 

5