Parminder Sanghera

Keeping our Communities  
Safe and Reassured 

Working in partnership, 
making communities safer 

STAFFORDSHIRE AND WEST MIDLANDS POLICE 
JOINT LEGAL SERVICES 

Director of Legal Services 

Your Ref: 

Our Ref: 

Email:

Dear Sir, 

Date: 27 September, 2024 

Prevention of Future Deaths report dated 
12 August 2024, Parminder Singh Sanghera 

I  write  in  response  to  the  Prevention  of  Future  Deaths  report  dated  the  12  August  2024  which 
followed  on  from  the  inquest  touching  upon  the  death  of  Mr  Parminder  Singh  Sanghera.  The 
report identified three key areas of concern to be addressed. 

1.  During the course of the inquest, I heard evidence Mr Sanghera was deemed to be 

suffering from behavioural issues rather than a mental health crisis and no full Mental 
Health Act assessment took place either at New Cross Hospital or whilst in custody at 
Oldbury Police station.   

2.  The risk assessments performed in hospital and police custody identified no concerns of 
risk of suicide or self-harm from release. However, evidence at the inquest showed that 
he was suffering from a mental health crisis at the time. 

3.  My concern is that given the erratic behaviour he was displaying and his vulnerability, 

further consideration should have been given for a full mental health act assessment to 
take place before release. Therefore, you may wish to consider reviewing the 
arrangements and assessments required before discharge from hospital or being 
released from custody. 

This letter is the response on behalf of the Chief Constable of West Midlands Police (WMP). I am 
Chief  Superintendent 
,  Head  of  Criminal  Justice  Services at West Midlands 
Police.  I  hold  responsibility  for  the  custody  portfolio.  Health  and  Justice  (previously  Liaison  and 
Diversion). Although, Health and Justice is an NHS commissioned service, located within WMP 
custody suites. 

Health and Justice 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Where a person is arrested for a Police and Criminal Evidence Act 1984 (PACE) matter and 
there are concerns that they are in mental health crisis, they will usually be referred to both a 
healthcare professional (‘HCP’) and Health and Justice, or Health and Justice alone, depending 
on the individual circumstances.  

Pursuant to the above, Mr Sanghera was referred to an HCP to assess his fitness to be 
detained. The HCP noted that he was calm and compliant, making good eye contact and 
speaking in coherent sentences.  He stated he had been hearing auditory voices for a few weeks 
but had no deliberate self-harm (DSH) or suicidal ideation at the time of the assessment. A plan 
was made for him to be referred to Liaison and Diversion the following morning (13 February 
2023). 

The role of Liaison and Diversion is to undertake screenings and assessments for a range of 
health and social care needs and other vulnerabilities in order to ensure those needs are being 
adequately addressed, to provide diversionary opportunities and ensure key decision makers 
within Criminal Justice Services (CJS) have sufficient understanding to make an informed 
decision.  

Liaison and Diversion staff (Community Psychiatric Nurses) were engaged by the custody 
sergeant on the day of Mr Sanghera’s release. They decided, after screening him, not to attend 
and speak to him. This was due to the fact he had been assessed by mental health services on 
the 9 and 12 February 2023. No acute mental health concerns and/or self-harm/suicidal intent 
had been noted during these assessments. Mr Sanghera had been referred back to his GP with 
an update to be provided to his current care provider. 

A decision was made by the investigation team that the offence Mr Sanghera was arrested for 
would be subject to No Further Action (NFA). Therefore, the power to legally detain Mr Sanghera 
in police custody under the provisions of PACE ceased. The criteria for continued detention to 
allow for a full assessment by an approved mental health professional and doctor under s136(2) 
of the Mental Health Act 1983 (MHA), namely that the person appears to be suffering from a 
mental disorder and in need of immediate care and control, was not met. In a custody setting, 
this assessment is made by a custody sergeant in consultation with a registered medical 
practitioner. 

A pre-release risk assessment was conducted and Mr Sanghera was released from custody. The 
process followed by the staff involved in Mr Sanghera’s detention adhered to the requirements of 
PACE, Approved Professional Practice (APP) and the WMP Custody Standard Operating 
Procedure (SOP).  

Where it is determined that a full mental health assessment is necessary pursuant to s136 MHA, 
it is normal practice for Health and Justice to coordinate this being conducted (during working 
hours). Outside of working hours this is coordinated by the custody healthcare provider, Mitie. 

In the event that the PACE matter is finalised prior to this assessment being conducted, 
circumstances will be considered on a case by case basis but it is usual practice for the person 

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 to be detained under s136 MHA. WMP officers are accustomed to applying the s136 criteria; as 
a force, we see particularly high volumes of s136 detentions within the custody environment. 

Changes since 13 February 2023 

Since the date of Mr Sanghera’s death, there have been a number of measures introduced within 
the custody environment aimed at continuously improving the level of care detained persons 
receive.  These are not solely in response to the death of Mr Sanghera, but as part of the 
continuous improvement of the custody function service within WMP. 

These improvements include: 

(i)  Over 90% of custody staff have completed the College of Policing vulnerability in custody 

training; 

(ii)  Pre-release risk assessments are now subject to monthly audits to ensure quality; 
(iii) Detained persons now receive a leaflet signposting to support service pathways, a copy 

of which is enclosed with this response; 

(iv) The Health Care Provider specification now includes a requirement for their staff to have 
access to Summary Care Records (Mitie became the service provider on 1 September 
2024 and have access to these records, whereas the previous provider did not). When 
the name, date of birth and address of the detained person is entered the Summary Care 
Records entry would provide an NHS number, GP details and potentially a pharmacy 
number. With the written consent of the detained person Mitie can then access further 
details covering current allergies; current acute and repeat medications; and discontinued 
medications. The system would not show why the detained person was on those 
medications. Sometimes a medical condition will be recorded for example epilepsy, 
asthma or diabetes. Mitie cannot access GP notes. Not everyone has Summary Care 
Records. For example, detained persons who are not UK residents or not registered with 
a GP. 

(v)  WMP is working with the Birmingham and Solihull Mental Health Trust, providing them 
access to Perry Barr custody suite which will enable them to identify and fill any gaps in 
the provision of mental health services within the custody arena, and expand available 
service pathways from this setting; 

(vi) Under “Right Care, Right Person”, WMP is working closely with mental health partners, 

again with the ambition to bring mental health services into the custody environment. This 
will ensure access to the appropriate service at the earliest opportunity, and enable 
officers to determine, at each stage of a person’s detention, whether that person’s health 
needs or the investigation takes primacy. 

The ultimate objective is to deliver a system wide response to those in mental health crisis.        

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 If WMP can be of further assistance in relation to this matter, please do not hesitate to contact 
me. 

Yours sincerely 

Head of Criminal Justice Services 
West Midlands Police 

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Dear Mr Siddique, 

We have been asked to assist Royal Wolverhampton NHS Trust (“the Trust”) in relation to 
your Regulation 28 Report to Prevent Future Deaths (PFD)  dated 12 August 2024.  The 
PFD followed the inquest of Mr Parminder Singh Sanghera and it is our understanding that 
it was addressed to the Chief Executive at the Trust as being a person with the power to 
take relevant action in relation to the concerns raised in the PFD.   

Those concerns are that no Mental Health Act Assessment took place at New Cross Hospital 
or  whilst  Mr  Sanghera  was  in  custody  and  have  suggested  that  the  Trust  might  wish  to 
review arrangements required before discharge from hospital. 

As you are aware, the Trust was not an Interested Person at the inquest (but provided factual 
witness evidence) and did not have the opportunity to make representations to the Coroner 
regarding  the  way  in  which  mental  health  services  are  provided.   It  did  not  have  an 
opportunity to address any concerns subsequently set out in, the PFD.  

Whilst  the  Royal  Wolverhampton  NHS  Trust  (the  Trust)  is  committed  to  delivering  an 
excellent  standard  of  care  to  all  patients,  including  those  with  mental  disorders/illness,  it 
does not deliver direct mental health services or mental health intervention and does not 
provide any mental health services.   The Trust does however, make referrals to the Mental 
Health Liaison Service which is provided by the Black Country Healthcare NHS Foundation 
Trust. 

The  Emergency  Department  at  New  Cross  Hospital  has  a  clear  procedure  in  place  for 
patients  whose  behaviour  is  causing  concern  without  an  identified  medical  cause  (see 
Document 1 attached),  This involves a referral to the Mental Health Liaison Service (see 
Referral Form, Document 2 attached). This service is available 24/7 and has response time 
of within 1 hour. 

The  Mental  Health  Liaison  Service  aims  to  provide  acute  mental  health  assessment, 
treatment  and  support  to  individuals  in  New  Cross,  West  Park  and  Cannock  Chase 

 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 Hospitals,  this  includes  patients  treated  in  the  Emergency  Department  and  assessed  as 
medically fit for discharge.  Part of the Liaison Service’s role is to assess acute mental health 
needs and ensure that they receive the help that they need, including undertaking a formal 
Mental  Health  Act  Assessment  with  a  view  to  detention  under  section  2  or  section  3  if 
considered to be necessary .  The referral criteria includes individuals who have “deliberately 
caused harm to themselves by overdose of medication or by other methods with suicidal 
intent”. 

On  the  two  occasions  during  February  2023,  the  9th  and  the  11th    when  Mr  Sanghera 
attended the Emergency Department, a referral was correctly made to the Mental Health 
Liaison  Service  provided  by  the  Black  Country  Healthcare  NHS  Foundation  Trust  in 
accordance with Trust protocol and he was assessed by them. On the 2 early occasions 
they determined  that he did not  have a mental disorder  (therefore  not  requiring  a  Mental 
Health Act assessment) with a view to being fit for discharge.  The Trust therefore do not 
have  the  power  to determine  next  steps  in  relation  to  a  patient’s mental  health  concerns 
when input has been sought appropriately from the menta health service.  

Further, on the latter attendance the 12th February, the Trust does not provide any mental 
health  “input”  in  relation  to  those  in  police  custody.  It  is  understood  that  this  would  be 
provided  by  the  Liaison  and  Diversion  Service  –  which  will  be  organised  at  a  local  level 
between  the  police  and  mental  health  services  and  is  subject  to  a  Memorandum  of 
Understanding between services.  Again, this is not something that the Trust would have 
any involvement in.  

We believe that the Coroner may be directing his concerns regarding mental health services 
to the wrong trust, however the Trust does wish to respond to the PFD as comprehensively 
as possible and to assist in clarifying how the various services interact.  As the Coroner will 
see there is no further relevant action within the Trust’s power which could have been taken 
by the Trust to address the Coroner’s concerns set in the PFD. 

We  hope  you  find  this  response  comprehensive.  If  you  require  any  further  information, 
please let us know. 

Legal Director 
Weightmans LLP