Khalid Yousef — PFD report 2022-0193

Date of report	23 Jun 2022
Reference	2022-0193
Deceased	Khalid Yousef
Coroner	James Bennett
Coroner area	Birmingham and Solihull
Category	Mental Health related deaths · Other related deaths
Source	judiciary.uk record · original PDF
Responses published	8

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

(1)
(2)

(3)
(4)

Trust.

CORONER

, Chief Executive NHS England.

, Chief Executive Birmingham and Solihull Mental Health

MP, Home Secretary.

, Chief Constable West Midlands Police.

I am Mr James Bennett, HM Area Coroner for Birmingham and Solihull.

CORONER’S LEGAL POWERS

I 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.

INVESTIGATION and INQUEST

On 17 January 2018 I commenced an investigation into the death of Khalid Seneen Yousef.
The investigation concluded at the end of the inquest on 8-17 June 2022.

CIRCUMSTANCES OF THE DEATH

After a post-mortem the cause of death was determined to be: 1a Decapitation.

On 4/1/18 Khalid was at Paddy Power on Rookery Road, Handsworth, Birmingham. At around
12:45hrs the perpetrator arrived in possession of four knives and commenced a sustained
assault. Khalid's main injuries were decapitation,

.

Alerted by staff the police arrived and the perpetrator was arrested on suspicion of murder.
Within 24 hours he was detained under the Mental Health Act. He was severely delusional
reporting he and Khalid were shapeshifting superheroes in a competition to find treasure at
the behest of the Queen as part of a league of extraordinary gentleman. He had transformed
into various beings and followed Khalid and decided to 'end the devil'.

He was not previously known to the mental health services. It was established his family had a
strong history of schizophrenia due to consanguinity. He was diagnosed with paranoid
schizophrenia which responded well to medication.

He stood trial for murder between 10-13/9/18 and was found not-guilty by reason of insanity
and made the subject of a mandatory hospital order under the Mental Health Act.

The background is as follows.

1

In 2007 the perpetrator completed a 5-year Medicine and Surgery degree in Sudan followed
by extra training in the USA achieving an exceptional score. There is no evidence he ever
worked as a doctor after arriving in the UK in 2013. Khalid's port-mortem examination
revealed his injuries had been carried out with skill.

On 3/11/17 the perpetrator's relatives were concerned as he was reporting an irrational fear
of foxes in the garden that no one else could see. This was not reported to the authorities.

On 9/12/17 he was stopped by police near his flat and was in the possession of nun-chucks
and a wheel-brace. He was released and told he would be informed later if any action was to
be taken. There were no obvious signs of any mental illness.

On 12/12/17 he was challenged and restrained by workers when found breaking into
commercial premises. He was arrested on suspicion of burglary and taken to Perry Barr
Custody Suite. A Force Medical Examiner noted no mental health concerns. On 13/12/17 he
was interviewed and stated the Queen was responsible for a league of extraordinary
gentleman and left clues that led to prizes. He had previously won prizes and had followed
clues that led him inside the building. The detective constable was concerned that his beliefs
appeared genuine and therefore referred him to Liaison and Diversion (L&D) located in the
custody suite.

The purpose of L&D was to screen patients for vulnerability and refer them onto appropriate
secondary services. He was seen by a band 6 mental health nurse in his cell for a maximum of
45 minutes. He repeated his belief he was part of the league of extraordinary gentleman. The
nurse did not recognise he was floridly psychotic and incorrectly decided he did not meet the
threshold for a formal Mental Health Act assessment and could not be referred to mental
health services. The nurse gave him a leaflet and advised him to contact a GP if he felt the
league of extraordinary gentleman was affecting his day-to-day life. The detective constable
did not want him to be released as she felt his beliefs would cause him to commit further
offences, albeit similar offences, but she considered L&D as the experts and did not challenge
the decision. The perpetrator was released from custody on bail under further investigation.

On 18/12/17 he was stopped and arrested after trying to evade the police when in possession
of a crowbar and detained until released on 19/12/17. There was no evidence to charge him
with an offence and he was released. There were no obvious signs of any mental illness.

Khalid and the perpetrator were known to each other. There is evidence they were friendly
but on occasion the perpetrator had dragged and pushed Khalid around. On 31/12/17 the
perpetrator visited Khalid at home and they left together seemingly on good terms. There is
no evidence the authorities were aware of their relationship or of any direct risk to Khalid.

The coroner’s conclusion as to the death was:

Khalid was killed by another person who was severely mentally ill and acted upon his
delusional beliefs. The significance of the perpetrator's presentation on 13/12/17 was not
appreciated and it meant he was not referred to mental health services when he should have
been. Had he been referred he would have received treatment and/or been detained and the
death would not have occurred. The decision to not refer him for treatment was a very
serious failure and occurred because of the L&D clinician's inexperience, inadequate training
and supervision, and the absence of psychiatrists within L&D to provide advice.

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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:

The L&D police custody suite model is a nationally commissioned service. It is a broad service
designed to identify persons in custody (PICs) with vulnerabilities and is generally successful at
signposting them to a variety of different secondary services. In relation to mental health L&D
is not intended to replace or duplicate secondary mental health services.

It was originally intended to commission psychiatrists within this L&D model but they were
removed from the final commissioned service. The expert evidence explained this decision is a
very serious flaw in commissioning. The reality is a small number of PICs will be seriously
mentally unwell or be developing a serious mental illness, in particular first episode psychosis.
Such people are complex and L&D practitioners, who are generally junior staff, are not
sufficiently trained or experienced enough to guarantee they will always recognise the
significance of symptoms and take appropriate action, as happened with the perpetuator in
this case. Therefore, L&D practitioners (who will include social workers, disability nurses,
speech and language therapists, and band 6 mental health nurses) need readably available
advice, support and reassurance from a Consultant Psychiatrist within L&D, even if only
available via a phone call. Having indirect, and often difficult, access to psychiatrists as part of
extended or secondary services is inadequate.

The expert evidence explained that the most comparable L&D model is in prison custody
where psychiatrists are commissioned, and there is no logical rationale for why L&D services
in prisons have commissioned psychiatrists but L&D services in police custody suites do not.
More widely, GPs (who are better trained and more experienced than L&D practitioners) have
access to Consultant Psychiatrists working for secondary mental health services who have it
written into their contracts to provide advice.

The expert evidence explained the risks arising from the “gap” in commissioning is
compounded by (1) police officers wrongly see L&D as mental health experts when they are
not (there was direct evidence of that in this case). The Clinical Director for BSMHFT also gave
evidence that some clinicians within BSMHFT also get confused about L&D’s role. It follows
whilst L&D is not there to replace or duplicate secondary mental health services there is
evidence police officers and clinicians do not fully understand L&D’s role and purpose and do
wrongly view them as experts; And (2) there has been a material reduction in both (a) the
number of Forensic Medical Examiners (FMEs) (commissioned by individual Chief Constables)
working in police custody suites generally, but also (b) the number of Forensic Medical
Examiners that are section 12 MHA 1984 approved. This reduction reduces the ability of L&D
practitioners to seek advice from FMEs. There is an overlap between FMEs and L&D
practitioners who both feed into police custody sergeants who have ultimate responsibility for
the health and safety of PICs. In reality there are two health care systems working in parallel,
however, multiple higher level local meetings have revealed a lack of clarity around who is
responsible for what.

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BSMHFT’s serious incident investigation (via the Root Cause Analysis (RCA) process) identified
the lesson learnt was that there was no psychiatrist in the L&D model and reported this to
NHS England. The evidence did not reveal the response.

Generally, the evidence revealed BSMHFT’s RCA process was unsatisfactory. An outside Trust
agreed to undertake the RCA investigation but returned it incomplete and the paperwork has
been lost. The circumstances were later reviewed by a Consultant Forensic Psychiatrist who
identified no care and service delivery issues were identified. However, the evidence at the
inquest did reveal matters of concern. BSMHFT had lost the relevant L&D practitioner’s
records which would have confirmed her training. The inquest evidence revealed concerns
around her experience, training and supervision in this case. Two senior BSMHFT witnesses
gave evidence there is now an intention to review induction and training of L&D clinicians. It
follows I am not satisfied appropriate lessons have at the time of writing been learned.

In summary, despite the death being 4 ½ years ago no changes have been made despite it
being identified the absence of psychiatrists is a flaw in the commissioning of the L&D police
custody suite model, compounded by the reduction in FMEs generally/section 12 approved
FMEs, and more generally the experience, training and supervision of L&D practitioners needs
to be reviewed by BSMHFT. In my view, there is nothing to suggest the same failures that
occurred on 13 December 2017 in this case will not happen again.

My specific concerns:

1. The L&D police custody suite model has not commissioned psychiatrists.
2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D

services on who has responsibility for mentally unwell persons in custody.

3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role

and limitations of the L&D police custody suite model.

4. BSMHFT have not learnt sufficient lessons from the incident and need to review

experience, training and supervision of L&D practitioners.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I 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 18 August 2022. I, 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

I have sent a copy of my report to the Chief Coroner of England and Wales, and to the
following Interested Persons: (1) Khalid Yousef’s family, (2) Birmingham and Solihull Mental
Health Trust, (3) West Midlands Police, and (4)

.

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I have also sent it to the following who may find it useful or of interest: (1)
– Consultant Forensic Psychiatrist, and
Special Responsibility for Forensic Psychiatry.

– Consultant Psychiatrist with

I 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
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
Date: 23 June 2022

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Signature:

Mr James Bennett, HM Area Coroner for Birmingham and Solihull

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Responses

8 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 Birmingham and Solihull Mental Health (PDF)

Legal Department 
B1 – Unit 1 
50 Summer Hill Road  
Birmingham 
B1 3RB  

James Bennett 
Area Coroner for Birmingham and Solihull 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

BY EMAIL ONLY  

Our Ref:    Yousef 

Your Ref:   222719 - Khalid Seneen YOUSEF (Karen Jones/RP)   

Date: 

15 August 2022   

Dear Mr Bennett, 

Re: Prevention of Future Deaths in the inquest of Khalid Yousef (deceased) 

Thank you for sharing the Prevention of Future Death’s report with us on 23 June 2022. We 
would like to assure you that the Trust takes your concerns very seriously. The incident which 
led to the inquest was a tragic set of circumstances and the Trust has taken action to respond 
to the concerns you have raised within your report. I intend to respond to each of the points in 
turn. 

1. 

The L&D police custody suite model has not commissioned psychiatrists. 

The  Birmingham  and  Solihull  Mental  Health  NHS  Foundation  Trust  gave  evidence  in  court 
during the inquest that the Liaison and Diversion Service follow the national model. The Trust 
is therefore unable to respond to the point around commissioning of psychiatrists within the 
model. We note that NHS England was also sent a copy of the Prevention of Future Deaths 
Report and we hope that they will be able to provide more information to you  in due course.  

Liaison and clarity is needed between Chief Constables and the Trusts providing 

2.  
L&D services on who has responsibility for mentally unwell persons in custody. 

The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational 
Group), where the Trust meet with the Police and other stakeholders on a regular basis. The 
next meeting is due to take place on 18th August 2022. The meeting will discuss how to share 
this information between agencies to ensure that the message is shared clearly and clarity is 
gained around what the Liaison and Diversion Service are responsible for.  

Customer Relations │ Mon – Fri, 8am – 6pm  
Tel: 0800 953 0045 │ Text: 07985 883 509      
Email: bsmhft.customerrelations@nhs.net 
Website: www.bsmhft.nhs.uk 

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 3.   West Midlands Police officers and BSMHFT staff do not sufficiently understand 
the role and limitations of the L&D police custody suite model. 

As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting 
in  August.  This  meeting  will  address  your  concerns  around  cross-agency  information. 
However, in order to address the internal issue around understanding the role of the Liaison 
and  Diversion  Service,  the  Manager  of  the  team  will  be  carrying  out  internal  work  with the 
Trust Communications Team to put a piece together as part of the weekly bulletin outlining 
what the team do. This will be completed in line with the outcome of the current tender for the 
new integrated offender health service, which will incorporate liaison and diversion in custody.  
This will ensure the greatest visibility, clarity and impact with the communication. We expect 
to be in a position to complete this in September 2022.  

BSMHFT have not learnt sufficient lessons from the incident and need to review 

4.  
experience, training and supervision of L&D practitioners. 

The Trust takes these issues very seriously. Up until the point of the inquest hearing the Trust 
was  not  made  aware  of  any  concerns  around  experience,  training  or  supervision  for  Ms 
Fitzgerald. On hearing the issues raised during the inquest, the Head of Patient Safety met 
with  the  Team  Manager  to  raise  these  matters  for  reflection  and  to  ascertain  if  any 
improvements are required.  This would be part of our usual process for reflective practice 
within the Trust. 

The  Team Manager is now working on a project which will be completed by the end of October 
2022  to  review  the  current  induction  programme  and  produce  an  up  to  date  induction 
programme  which  is  suited  to  different  team  roles  and  areas  of  work.  This  will  include  an 
induction pack, shadowing and training package for all new staff and students. As part of the 
new tender process which is also currently taking place, the Trust have also planned to have 
psychologists join the L&D for reflective practice groups which are to take place. Through this 
work  there  will  be  assurance  that  training,  supervision  and  experience  are  a  priority  and 
changes are made where necessary. 

Please  be  assured  that  the  Trust  will  continue  to  make  any  necessary  changes  or 
improvements to ensure patient safety and learn lessons from incidents in the future.  

Yours  sincerely, 

Chief Executive

Response from Home Office (PDF)

Home Office 

' 

James Bennett 
HM Area Coroner 
Birmingham & Solihull Areas 
Steelhouse Lane 
Birmingham 
B4 SBJ 

Home Secretary 

2 Marsham Street 
London SW1 P 4DF
www.gov.uk/home-office 

h~  January 2023 

Thank you for your letter of 15 November 2022 regarding the Regulation 28 Report to 
Prevent Future Deaths which was sent to the former Home Secretary, the Rt Hon Priti 
Patel MP. 

I would like to express my sympathies to the family of Khalid Seneen Yousef.  I also 
wish to apologise for the very long delay in responding to you about this report.  I have 
asked my office to investigate the circumstances surrounding your previous 
correspondence of June, September and October which we have no record of receiving. 

I note that you have already received detailed responses from the Chief Constable of 
West Midlands Police and from the National Medical Director of NHS England in 
response to your concerns. 

The commissioning of Liaison and Diversion Services is a matter for NHS England.  The 
tendering and commissioning of all police custody healthcare services is the 
responsibility of Police and Crime Commissioners and their forces and it is for them to 
take decisions on how to allocate resources based on their local knowledge and 
experience.  Therefore, it would not be appropriate for the Home Office to comment or 
intervene in either of these two services. 

I can confirm that NHS England continues to provide national support and oversight to 
the National Police Chiefs' Council (NPCC) in respect of healthcare being delivered in 
police custody suites, which includes maintaining the integrity and standards for the 
NPCC Police Custodial Healthcare Service Specification and its alignment with NHS 
England's Liaison & Diversion national service specification.  This supports NHS 
England's undertaking to voluntarily provide support to our colleagues in policing.  NHS 
England confirm, that to the best of their knowledge the service specification is used by 
all forces as part of their tendering for new custodial services and is regularly reviewed 
by a variety of stakeholders including the Faculty of Forensic and Legal Medicine and 
other distinguished medical experts and police custody leads, in order to ensure that 
any policy or legislative changes are reflected. 

 
 
 It is reassuring to note that West Midlands Police acknowledge that operational 
improvements can be introduced in respect of your findings in the report.  It is important 
to also note that in  addition to those changes, that when someone passes the threshold 
from the Liaison and Diversion service to identify, assess and report on a person's 
vulnerability and moves towards a crisis situation the police can seek a Mental Health 
Act assessment via the local authority duty.  This process can be supported by the 
police healthcare provider and by the Liaison and Diversion service on a voluntary and 
supportive basis within current service specifications. 

I can also confirm that Home Office officials work very closely with the NPCC, NHS 
England, the Department for Health and Social Care on a range of different issues 
relating to mental health and how healthcare partners and the police can work together 
most effectively.  Currently, they are collectively working on how to improve escalation 
processes between the police and NHS and how mental health is managed in the 
custody environment with a view to the NPCC issuing guidance on effectively managing 
these referral pathways. 

I trust that this provides some reassurance to you. 

Rt Hon Suella Braverman KC MP

Response from NHS England (PDF)

Mr James Bennett
Her Majesty’s Area Coroner for
Birmingham and Solihull
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ

National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG

26 October 2022

Dear Mr Bennett

Re: Regulation 28 Report to Prevent Future Deaths – Khalid Seneen Yousef who
died on 4 January 2018

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23
June 2022 concerning the death of Khalid Seneen Yousef on 4 January 2018. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Mr Yousef’s family and loved ones. NHS England
are keen to assure the family and the Coroner that the concerns raised following Mr
Yousef’s death have been listened to and reflected upon. I would also like to sincerely
apologise for the delay in responding to your Report.

Following the inquest, you raised a number of concerns in relation to the Liaison and
Diversion (L&D) police custody suite model, which is a nationally commissioned
service, and access to psychiatrists. With input from the NHS England West Midlands
regional Health and Justice team, I have responded to each of your specific concerns
in turn below:

1. The L&D police custody suite model has not commissioned psychiatrists.

In terms of the commissioned health services that operate within police custody
suites, there are two services as follows:
• A police custody healthcare service (PCHS). PCHS is commissioned by the
Police & Crime Commissioner (PCC) for each force. The National Police Chiefs’
Council (NPCC) issue a national service specification for this service, although
this takes the form of guidance for PCC’s rather than being mandatory. The
PCHS is responsible, inter alia, for advising the police on fitness to detain,
fitness to interview and fitness to charge (in accordance with the provisions of
the Police & Criminal Evidence Act 1984).

• Liaison and diversion service (L&D). This service is commissioned by NHS
England, via regional Health & Justice teams, in accordance with a published
at
national
https://www.england.nhs.uk/publication/liaison-and-diversion-standard-
service-specification/. The L&D service seeks to identify and assess individuals

specification

service

which

found

can

be

with vulnerabilities, make supported referrals to appropriate services and, with
the individual’s consent, share relevant information with key decision makers
within criminal justice agencies.

The NPCC national service specification (Annex 1) specifically
includes
responsibility for responding to individuals in mental health crisis, including placing
a requirement on the provider to facilitate assessments under the Mental Health
Act. The NHS England L&D national service specification, by design, specifically
excludes these functions.

The inclusion of psychiatric provision within the makeup of L&D multi-disciplinary
teams is not presently considered necessary. If and when an L&D practitioner
identifies secondary mental health needs, that do not require immediate
intervention, a supported referral is made to the appropriate local community
mental health service. The PCHS operates within police custody suites 24 hours a
day, whereas L&D services are generally present for 12 hours a day. In the event
of a Mental Health Act assessment being required, this would be facilitated by the
provider through the PCHS rather than L&D. As stated below, the two services
work closely and their specifications make clear who has responsibility for
responding to those in mental health crisis.

In summary, it is not the responsibility for L&D services to respond to those in
mental health crisis, that function falls to PCHC services. Where an L&D
practitioner has concerns regarding an individual’s mental health, that falls short
of requiring an immediate crisis response, the expectation is that they will liaise
with that individuals community mental health team for further advice (which may
involve speaking with a psychiatrist or psychologist) and if the person has
disengaged will provide a supported referral back into that service.

2. Liaison and clarity is needed between Chief Constables and the Trusts
providing L&D services on who has responsibility for mentally unwell
persons in custody.

The PCHS and L&D national service specifications are written to complement each
other, and to make clear which service is responsible for responding to those in
mental health crisis. NHS England’s national Health & Justice team officials work
closely with their counterparts at the NPCC to ensure that the two specifications
remain aligned.

NHS England works collaboratively with all agencies and stakeholders to ensure a
clear understanding of responsibilities for mentally unwell persons in custody.
Recently, NHS England presented at the NPCC Custody Forum Conference
(September 2022) and took the opportunity to emphasise the respective roles and
reinforce the responsibilities of the PCHS and L&D service when responding to
those in mental health crisis.

3. West Midlands Police officers and BSMHFT staff do not sufficiently
understand the role and limitations of the L&D police custody suite model.

A copy of the response from BSMHFT has been shared with NHS England, the
response of the Chief Constable has not been shared.

I understand from the NHS England West Midlands regional Health & Justice team
that this matter has been raised at the force’s Joint Strategic Operational Group.
This is a governance meeting where the police meet with health and wider
partners, to provide clarity as to the responsibility of services to respond to those
in mental health crisis, and to ensure that appropriate messages are regularly
disseminated both to police and health audiences.

4. BSMHFT have not learnt sufficient lessons from the incident and need to

review experience, training and supervision of L&D practitioners.

I am assured that NHS England’s regional Health & Justice commissioning team
are addressing this matter directly with the BSMHFT through regular contract
review meetings.

BSMHFT responded as follows to the issues raised:

“The Trust takes these issues very seriously. The Team Manager is now working
on a project which will be completed by the end of October 2022 to review the
current induction programme and produce an up to date induction programme
which is suited to different team roles and areas of work. This will include an
induction pack, shadowing and training package for all new staff and students. As
part of the new tender process, the Trust have also planned to have
psychologists join the L&D for reflective practice groups which are to take place.
Through this work there will be assurance that training, supervision and
experience are a priority and changes are made where necessary”

The Regional Commissioner will further discuss this case and progress on the
above actions at the next scheduled contract meeting (October 2022). The
outcome of that meeting will be included in the November 2022 Quality Report
and presented to the Health and Justice Assurance and Improvement Group,
where next steps will be agreed.

NHS England commissioned Health Education England (HEE) and Skills for Health
(SfH) to produce a career and competency framework for L&D services Career and
Competence Framework | Info Hub | Skills for Health. This framework was
published on 31 May 2018 and clearly sets out the respective job roles required
within a multi-disciplinary L&D team, and the competencies required to discharge
those roles. HEE and SfH are currently reviewing the content, as part of a wider
piece of work to develop a career and competency framework across all of our
Health & Justice non-custodial programmes of work.

NHS England regional Health & Justice commissioners will have regard to the
framework when addressing workforce and quality issues with providers.

I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical

Directors and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the tragic death of
Mr Yousef, are shared across the NHS at both a national and regional level, and
helps us to pay close attention to any emerging trends that may require further
review and action.

Once again, thank you for bringing these important concerns and issues to my
attention. I hope my response reassures you that appropriate services and
measures are in place to ensure the safety and wellbeing of those individuals with
specific mental health vulnerabilities, but that further action is being taken to review
and improve certain aspects of these services.

Please do not hesitate to contact me should you need any further information.

Yours sincerely,

National Medical Director

ANNEX 1

20220817 Master
Police Custody Nat S

Response from NHS England 1 (PDF)

Mr James Bennett 
Her Majesty’s Area Coroner for 
Birmingham and Solihull 
The Birmingham and Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

National Medical Director 
NHS England 
Wellington House 
133-155 Waterloo Road
London 
SE1 8UG 

Date 

Dear Mr Bennett 

Re: Regulation 28 Report to Prevent Future Deaths – Khalid Seneen Yousef 
who died on 4 January 2018 

Thank  you  for  the  email  from  your  office  dated  21  November  2022,  in  which 
,  Consultant  Forensic  Psychiatrist,  is 
communication  from 
shared. Please accept my apologies for not responding sooner. 

 has highlighted his concerns around healthcare provision for individuals 
experiencing mental health crisis whilst in custody and points out the difference in 
the  responses  from  NHS  England  and  West  Midlands  Police  on  this  matter, 
specifically in relation to the role of the Police Custody Healthcare Service (PCHS) 
and the potential risk that the current gap in provision will remain. It is noted that the 
response  from  West  Midlands  Police  dated  10  August  2022  does  not  make  any 
mention of the PCHS.  

In response to 

 concerns, I am able to respond as follows: 

Police Custody Healthcare Service (PCHS) 

The policy for the PCHS lies with the Home Office. Operationally, each Police and 
Crime Commissioner (PCC) is required to commission a PCHS for their police force. 
The National Police Chiefs Council (NPCC) maintains a national PCHS specification 
and  NHS  England  acts  in an  advisory  role to  ensure  that PCHS  and Liaison  and 
Diversion (L&D) specifications align.  

The NPCC specification is guidance rather than mandatory, which leaves PCCs free 
to determine the scope and extent of their PCHS provision and, as a result, there 
may be variation across areas in terms of the investment of resource to this.  

  point  may  have  some  substance  in  that,  unless  all  police  forces 
observe and adhere to the NPCC specification, their ability to respond appropriately 
to those in mental health crisis may be compromised, to include arranging a Mental 
Health Act assessment where appropriate. On this basis, it is my suggestion that 

 
 either  the  Home  Office  or  the  NPCC  would  be  best  placed  to  respond  to 

  specific  concerns  in  this  case.  I  am  aware  that  a  response  from  the 
Secretary of State for the Home Department was outstanding as at 15 November 
2022, and  the  Coroner has  requested a  response  by  no  later than  31  December 
2022. 

The Home Office’s position usually indicates that it is for each PCC to determine the 
level  of  healthcare  provision  required  for  their  area,  however,  NHS  England 
acknowledges  that  unless  each  PCHS  is  designed  to  fit  with  the  L&D  service 
specification and other locally commissioned services, then the potential for gaps in 
service  provision  will  remain.  It  would  not  be  practicable  for  NHS  England  to 
commission a service to take on the role of the PCHS, and instead the PCHS and 
L&D service should continue to work closely, ensuring that the service specifications 
and  responsibilities  are  clear,  aligned  and  understood.  NHS  England’s  national 
Health  &  Justice  team  officials  will  continue  to  work  collaboratively  with  their 
counterparts at the NPCC in this regard. 

Once again, thank you for bringing the important concerns and issues highlighted 
by this case to my attention. I hope my further response offers some clarity regarding 
the position with PCHS and L&D services. 

Please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director