Zahra Mohamed

HM Courts and Tribunals Service 
Bedford Magistrates’ Court 
Shire Hall 
3 St Paul’s Square 
Bedford MK40 1SQ 

7 August 2025 

HM Assistant Coroner Sarah Bourke  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London N1C 4PP  

Dear Ms Bourke, 

I would like to start by expressing my sincere condolences to the family and friends of Ms 
Zahra Sharif Mohammed.  

On behalf of HMCTS, I write to provide our response to the matters of concern addressed to 
the Magistrates’ Courts in your Report to Prevent Future Deaths, dated 18th February 2025, 
following the inquest into the death of Ms Zahra Sharif Mohammed. 

The Coroner’s MATTERS OF CONCERN are as follows: 

(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. 
However, if an application had been submitted to the magistrates’ court that day, it is unlikely 
that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was 
informed by a number of mental health professionals that the time taken for a s135(2) 
warrant to be obtained from the magistrates’ court and executed by the police was in the 
region of 2 weeks.  

(2) The process for obtaining a warrant is that an application has to be made for a video 
hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for 
a hearing to be arranged as the courts consider applications from all 32 London Boroughs. 
Once the Magistrates issued a warrant, an appointment would then be arranged for the 
police to execute the warrant.  

(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case 
in the summer of 2024.  

(4) I also heard evidence that the mental health team could attend Highbury Corner 
Magistrates’ Court in person to apply for a warrant in urgent cases but that they were 
actively discouraged from using this process by the court.  

(5) The court heard that the process and timescale for issuing and executing warrants had 
led to the hospital team adopting a practice of asking the community team to encourage a 
patient to return to hospital voluntarily before making an application for a warrant.  

(6) There is an ongoing risk that patients will harm themselves or others in the period before 
the warrant can be executed. This includes a risk of fatal harm. 

 
 
 
 
 
 HMCTS Response 

On behalf of HMCTS I offer our apologies for the delay in submitting this response to your 
report dated 18 February 2025.  Following some unfortunate internal misdirection the report 
was only received in the correct part of the MOJ in June and we are grateful to have been 
allowed time to investigate before providing our response. 

Our initial investigation concerned our position in relation to the Inquest.  Bearing in mind the 
content of the Prevention of Future Death reports which contain clear criticism of the service 
provision by London Magistrates’ Courts, we express our surprise that the MOJ (HMCTS) 
were not considered as falling within the status of Interested Parties to be joined by the 
Assistant Coroner under s.47 Coroner’s and Justice Act 2009.  The results of our 
investigations below would indicate that we had potentially relevant evidence to give in 
relation to the operation of systems for considering s.135 Mental Health Act warrants.  The 
Assistant Coroner has reached findings based on the witness evidence of other professional 
colleagues but without the evidence of HMCTS witnesses. 

Understandably, in these circumstances, we are now grateful for the opportunity to provide 
our insights on this sad case. 

Responding to the relevant parts of the ‘matters of concern’ in Ms Zahra Sharif 
Mohammed’s case: 

1) Listing is a judicial function and responsibility and arrangements for the operation of court 
lists are agreed with the judiciary and implemented by HMCTS.  Arrangements for s.135 
MHA warrants fall into these arrangements. 

Listing arrangements categorise mental health warrant applications as priority one work. It is 
acknowledged that this area of work carries the highest risks and vulnerabilities, therefore, it 
is prioritised in terms of the allocation of court time. Where necessary other work types will 
be adjourned off to prioritise the allocation of court time to deal with priority one work. 

Prior to the pandemic, a mental health practitioner who was applying for a mental health 
warrant could attend court and apply for the warrant. HMCTS operated (and still operates) 
an open-door policy for this category of priority one work. At the beginning of the pandemic 
there was a duty of care on HMCTS to protect court users and to embrace, wherever 
possible, remote ways of working. HMCTS swiftly responded and introduced a remote 
application system for mental health warrants, accompanied by an online booking system for 
applicants. The success of this system was such that once pandemic protection measures 
were removed applicants asked for the system to continue.  

The search warrant remote process was specifically designed to meet the needs and 
demands of the 32 London boroughs it serves. Since the inception of the remote process 
HMCTS has provided daily access to two separate, remote warrant sessions through 
Monday - Friday. The system is set up as online self service, which means applicants can 
select hearing dates and times for their applications. Where sessions have been booked in 
advance (it is not unusual and indeed is commonplace for applicants to cancel slots) those 
slots are released back to the booking in system.  

This business-as-usual model ensures that HMCTS, on average, provides more warrant 
slots than the applications it receives daily.  

 
 
 Alongside the self-service online booking process, HMCTS retained and retains an open-
door policy which is widely known and accepted practice and procedure. This process invites 
applicants to attend court, which provides immediate access to a court room, where the 
mental health warrant application will be listed. Applicants are encouraged to contact the 
centralised administration team who deal with such applications, in order that they can be 
directed to their local courthouse.  However, should an applicant attend a local courthouse 
without contacting the centralised administration team, it remains the practice that the court 
will accommodate the applicant, given the nature and priority given to such applications.  

Whilst there is a maximum number of hearing slots within the online booking system for non-
urgent cases, the applicant’s access to a court hearing is not limited to the online booking 
slots. It is long established practice and procedure for mental health practitioners to attend 
court and apply for urgent mental health warrants.  

Additionally, the court provides a daily out of hours service for such applications, ensuring 
that the ability to apply for a mental health warrant is not hampered or impeded by a lack of 
access to the Judiciary. Again, there is an over-provision of this service, to ensure that there 
are no delays in the out of hours operations.   

As a result of the various access routes to obtain an urgent mental health warrant, there is 
no need for an applicant to wait several days for a hearing.  

HMCTS was not present in the Inquest proceedings, not being joined as an Interested Party, 
and so was given no opportunity to assist the Assistant Coroner’s inquiry.   

HMCTS does not accept the evidence presented that the timeline of 2 weeks for application 
to execution includes a delay at the magistrate court application stage of the process. 

Had the application been considered and assessed as urgent, as above, emergency 
procedures are well established for applications to be made within the working week – and 
out of hours on a 24/7 basis.   

Noting the response provided by the Metropolitan Police, it is also clear that additional 
powers are available in case of emergency alongside the provisions of s135 MHA should 
these have been required. 

It follows therefore, that HMCTS asserts that ‘if an application had been submitted to the 
magistrates’ court that day (i.e. 4 October 2022)’, as an urgent application, that it is highly 
likely that the warrant would have been issued that day.    

2) As above, had the case been considered urgent, established procedures exist.  Guidance 
to practitioners describing the scheme for booking non-urgent, urgent and out of hours 
applications has been provided by HMCTS.  Regular inter-agency meetings provide fora for 
discussion about service provision.  No concerns about service provision have ever been 
raised with HMCTS by NHS colleagues.  The warrant courts at Westminster and Uxbridge 
provide sufficient supply of hearings for non-urgent applications based on data analysis and 
reviews over time.  All London magistrates’ courts are available at any time for urgent 
applications.  A central team provides access to urgent applications on request.  This service 
is used relatively frequently by AMHPs. 

3) HMCTS disputes the evidence presented to the Inquest that a 2-week timescale applied 
to obtaining a slot for a warrant hearing at the time in 2022 or up and until summer 2024.  
Had HMCTS been joined as a party we would have had the opportunity to provide rebuttal 
evidence and positively confirm the arrangements as described above for urgent warrants, if 
a non-urgent slot was not available in the time required. 

 4) As above, HMCTS has not been given the opportunity to provide our evidence on this 
point in the Inquest as an Interested Party.  Our detailed internal review of service provision 
concludes our position, and we dispute the evidence presented about discouragement of 
applications to Highbury Corner magistrates’ courts.  Our witnesses would have positively 
adduced evidence to the contrary. 

5) As above, we found no evidence following our review to support the perceived position of 
delays in the issue of non-urgent or urgent warrants.  

6) Immediately on receipt of this report and in response to exchanges between HMCTS and 
NHS colleagues, we have re-iterated the arrangements for applications to be made to 
magistrates’ courts in London whether routine, urgent or out of hours.  A meeting to explore 
any concerns was arranged and held in July between senior HMCTS and NHS 
professionals.  Continued communication of our arrangements will form part of our ongoing 
service and renewed commitment to partnership working to understand and resolve how 
serious misconceptions of service provision could have occurred amongst some AHMPs.   
We remain confident that our arrangements provide excellent access to AMHPs for urgent 
and emergency warrants.  

Publication and reporting 

We take a neutral position on the Chief Coroner’s decision on the release and or publication 
of our response, save to point to the potential for any additional distress to be caused to the 
family of Ms Zahra Sharif Mohammed by the noted disagreement between HMCTS and NHS 
positions which were unable of being resolved during the Inquest process given our 
absence.  We are content that the Chief Coroner will use diplomacy accordingly given the 
sensitivities to the family. 

We thank you for the opportunity to provide these observations which are designed primarily 
to give assurance that our magistrates’ court arrangements are suitable for the urgent 
consideration of these important mental health warrant applications, necessarily prioritised 
under our joint arrangements with the judiciary in full recognition of the vulnerability and risks 
to patients and the public. 

We hope this contribution has been of assistance and confirm our standing commitment to 
working with colleagues to continually improve services. 

Yours sincerely, 

Courts and Tribunals Director, HMCTS, on behalf of 
HMCTS 

, Chief Executive

HM Assistant Coroner Sarah Bourke  
Inner North London 
St Pancras Coroner’s Court 
Camley Street  
London 
N1C 4PP 

Deputy Assistant Commissioner 
Metropolitan Police Service 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Email: 

9 April 2025 

Dear Ms Bourke,  

I would like to start by expressing my sincere condolences to the family and friends of Mrs Zahra Sharif 
Mohamed. 

On behalf of the Commissioner of Police of the Metropolis, I write to provide our response to the matters of 
concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths, 
dated 18th February 2025, following the inquest into the death of Mrs Zahra Sharif Mohamed.   

The Coroner’s “Matters of Concern”  

The MATTERS OF CONCERN are as follows –  

(1)  It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an 
application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would 
have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental 
health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court 
and executed by the police was in the region of 2 weeks.  

(2)  The process for obtaining a warrant is that an application has to be made for a video hearing at either 

Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as 
the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, 
an appointment would then be arranged for the police to execute the warrant.  

(3)  I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer 

of 2024.  

(4)  I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in 

person to apply for a warrant in urgent cases but that they were actively discouraged from using this 
process by the court.  

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 (5)  The court heard that the process and timescale for issuing and executing warrants had led to the 

hospital team adopting a practice of asking the community team to encourage a patient to return to 
hospital voluntarily before making an application for a warrant.  

(6)  There is an ongoing risk that patients will harm themselves or others in the period before the warrant 

can be executed. This includes a risk of fatal harm.  

MPS Response:  

Community Consultation Meetings 

Applications under section 135(2) of the MHA can be made by Approved Mental Health Professionals 
(AMHPs) (who are usually specially trained social workers), the police or anyone authorised by hospital 
managers. The person applying for the warrant should be the professional with the most relevant and 
accurate information about the individual concerned. 

Before a s.135(2) MHA warrant is applied for, a Community Consultation Meeting will take place with 
AMHPs and the local Basic Command Unit (BCU) mental health point of contact. 

Community Consultation Meetings are informal collaborative arrangements that are supported by senior 
NHS personnel. Guidance was sent by the MPS to AMHP leads of London on 17th November 2022 setting 
out the expectations of the meetings: 

‘The MPS will now request a weekly Community Consultation Meeting between AMHPs, MH policing 
teams, Neighbourhood policing teams, Crisis Teams, and Home Treatment Teams (HTT) to discuss those 
people who may be reaching the threshold for an assessment/S135 warrant application. 

The purpose of this is to ascertain what has already been done within the community to help the person, 
what involvement, if any, the Neighbourhood Team have had and what more could be done prior to the 
AMHP requesting police assistance at a mental health act assessment/warrant.   

There must be agreement by all parties for the AMHP to continue to the warrant application stage and 
request police assistance through the on-line portal. 

Confirmation as to whether this “pre–consultation” has taken place will be built into the online portal.  

For urgent high-risk cases we would urge AMHPs to contact their MH policing teams/Ops rooms to discuss 
the need for police assistance outside of the Community Consultation Meeting process. This will constitute 
‘pre-consultation’.’ 

Representatives from partner agencies and local policing mental health points of contact attend Community 
Consultation Meetings to discuss individuals prior to the application to the Court for a warrant. The key 
purpose of these meetings is to ensure that all alternative options to a s.135(2) MHA warrant have been 
explored, with the aim of both protecting the individuals’ rights and to ensure rapid and appropriate care.  

If a warrant appears to be the last option available, an application to the Magistrates’ Court will be made. If 
the application is made by an AMHP/duly authorised person a request for police attendance will be 
submitted. 

In the period between the application for the s.135(2) warrant being made and the Court either granting or 
refusing the application, the MPS will consider whether an immediate police response is required. 

Applying for a warrant under Section 135(2) of the Mental Health Act (MHA) 1983 

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 As noted above, applications under section 135(2) of the MHA can be made by AMHPs, the police or 
anyone authorised by hospital managers.  

The purpose of a s.135(2) MHA warrant is to allow police to enter premises for the purpose of returning an 
individual sectioned under the MHA to a place of safety.  

A Magistrate can issue a warrant under s.135(2) MHA if they are satisfied that: 

(a)  there is reasonable cause to believe that the patient is to be found on the premises; and 

(b)  admission to the premises has been refused or that a refusal of such admission is apprehended. 

The warrant allows a police officer to enter premises by force if necessary and take the person to hospital 
or another appropriate location.   

Executing a warrant obtained under section 135(2) MHA 1983 

After a warrant is obtained, information held on police databases about the person concerned is reviewed 
and a risk assessment is conducted.  This enables officers to make an informed decision as to the police 
resources required to execute the warrant and ensure the safety of attending officers, any healthcare 
professionals and the individual. 

All the risks and control measures are recorded on a MHAA RA3 form which is reviewed and ratified by a 
supervisor.  

There is no legal requirement for AMHPs or other healthcare professionals to accompany police to execute 
a warrant, however the general practice is that they will. In such cases, a mutually convenient time and 
date is agreed to execute the warrant.  

The MHAA RA3 form was created following a review of police processes under section 135 MHA by the 
Health and Safety Executive in October 2022.   

The key responsibilities of the police when executing a s.135(2) MHA warrant are: 

1.  Entering the Premises –  

  The police officer has the legal authority to enter the property, using force if necessary 
  Entry must be reasonable and proportionate, prioritising de-escalation. 

2.  Ensuring Safety –  

  The police must assess any risks and ensure the safety of the person, healthcare professionals and 

 

anyone else present  
If there is a risk of harm, it may be necessary for officers to use reasonable force under the MHA 1983 
and common law.  

3.  Assisting with Removal –  

  Once entry is gained, the police work with mental health professionals to encourage the person to 

 

comply voluntarily. 
If necessary, the police can physically remove the individual to ensure their safe return to a hospital or 
another appropriate setting.  

4.  Handover to Healthcare Professionals –  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Once at the hospital or designated place, responsibility for the individual is transferred to mental health 

professionals.  

The Magistrate who grants the warrant will stipulate the validity period on the face of it. However, it is 
normal for the warrant to expire three months after its date of issue if it has not been executed.   

Timescale for execution of s.135(2) MHA warrants 

During the inquest into Mrs Mohammed’s death, the Court heard that in the summer of 2024 the time taken 
for a s.135(2) warrant to be obtained from the Magistrates’ Court and executed by the police was in the 
region of 2 weeks.  

The MPS cannot comment on the length of time taken to receive a listing for an application for a s.135(2) 
warrant to be heard as this is a matter for the courts. However, the average time taken from application to 
execution is currently between 10 and 20 days.  

Furthermore, it is expected that if the person concerned is considered to be high risk, that this is highlighted 
to the local Borough Command Unit (BCU) mental health point of contact who may be able to arrange for 
execution of the warrant as a priority. For urgent high-risk cases AMHPs are encouraged to contact their 
local BCU mental health point of contact to discuss the need for police assistance outside of the 
Community Consultation Meeting process. The AMHP/duly authorised person can also apply for the 
s.135(2) warrant and call 999 or 101 to request police assistance. They would then complete the risk 
assessment and submit the MHAA RA3 form retrospectively.  

The MPS acknowledges that there may be an ongoing risk that patients will harm themselves or others in 
the period before the warrant can be executed and every effort is made to secure an early date for 
execution of the warrant once it has been issued. However, it is imperative that a holistic and thorough risk 
assessment is carried out prior to the warrant being executed to ensure that appropriate measures are put 
in place to protect both the person concerned and also those professionals involved in executing the 
warrant.  

The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this 
PFD report and learning identified will be incorporated into this.   

Please do not hesitate to contact me should you require any additional information or clarification regarding 
the contents of this response. 

Yours sincerely, 

Deputy Assistant Commissioner 

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