Ronald Bainborough

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 Mr 
Bainborough.  

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 Mr Bainborough. 

The Coroner’s MATTERS OF CONCERN are as follows: 

(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved 
Mental Health Act Professional (AMHP) regarding the timescales for applying for and 
executing s135(1) warrants. All of them had concerns about the time taken for a warrant to 
be issued and executed  

(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the 
hearing took place on 23 August and it was intended that the warrant would be executed on 
7 September 2023. This was a timescale of 20 days. The jury was told that this timescale 
was typical of the time taken to apply for and execute a s135(1) warrant in the experience of 
the professionals giving evidence at the Inquest.  

(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts 
which consider applications from all 32 London Boroughs. There are a limited number of 
video hearing slots, so AMPH teams may have to wait several days for a hearing.  

(4) Once a warrant has been issued, an appointment then needs to be arranged for police 
officers to execute the warrant. The evidence before the court was that it would generally 
take in the region of 10 days for an appointment to be scheduled.  

(5) There is no official fast track procedure. Consequently, there is a risk of harm to the 
individual and others during the time taken for a warrant to be granted and executed. 

(6) As individuals have been identified as requiring assessment under the Mental Health Act, 
the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk 
that individuals will harm themselves or others 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 Mr Bainborough’s case 
using the coroner’s numbering: 

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 

Our 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.  

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.   

2) Whilst there is a maximum number of hearing slots within the online booking system, 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, HMCTS provides an out of hours service 7 days a week, where an applicant 
can access the Judiciary to apply for an urgent mental health warrant application. 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.  

Evidence presented to the Inquest confirmed that the application was made on 18 August 
with an intended date for execution on 7 September 2023. 

On that basis, it clearly follows that this was not regarded as an urgent application.   

The warrant was considered and granted on 23 August, 3 standard working days following 
submission.  There is no delay attributable in this case to the court listing process on a non-
urgent submission.   

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. 

3) As above, the application was considered 3 working days after submission.  Had the case 
been considered urgent, established procedures existed.  Guidance to practitioners 
describing the scheme for booking non-urgent, urgent and out of hours applications had 
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. 

4) This matter does not apply to the magistrates’ courts responsibilities. 

5) I interpret the reference to the absence of official fast track procedure as relating to the 
police element of the procedure, i.e. arrangements for execution of the warrant.  I note that 

 the Metropolitan Police confirm in their response that they have no official fast track 
procedure for execution of warrants.  This is not the case for applications for warrants to the 
magistrates’ court.  Perhaps, on consideration of evidence in the absence of any from 
HMCTS, there has been a conflating of process here reaching a conclusion which is contrary 
to our researched and evidenced position. 

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 Mr Bainborough 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

e 

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 Mr Ronald 
Bainborough. 

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 Mr Ronald Bainborough.   

The Coroner’s “Matters of Concern”  

The MATTERS OF CONCERN are as follows –  

(1)  During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health 

Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All 
of them had concerns about the time taken for a warrant to be issued and executed.  

(2)  The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took 

place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This 
was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply 
for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.  

(3)  Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider 

applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH 
teams may have to wait several days for a hearing.  

(4)  Once a warrant has been issued, an appointment then needs to be arranged for police officers to 

execute the warrant. The evidence before the court was that it would generally take in the region of 10 
days for an appointment to be scheduled.  

(5)  There is no official fast track procedure. Consequently, there is a risk of harm to the individual and 

others during the time taken for a warrant to be granted and executed.  

(6)  As individuals have been identified as requiring assessment under the Mental Health Act, the risk of 

potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will 
harm themselves or others before the warrant can be executed. This includes a risk of fatal harm. 

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 MPS Response:  

Community Consultation Meetings 

Applications under section 135(1) of the Mental Health Act (MHA) are applied for by an Approved Mental 
Health Professional (AMHP). Before an AMHP can request police attendance at a pre-planned Mental 
Health Act assessment, there must be a Community Consultation Meeting with 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 by an AMHP to the Court for a warrant. 
The key purpose of these meetings is to ensure that all alternative options to a s.135(1) 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, the AMHP will make the application to the Magistrates’ 
Court and submit a request for police attendance. 

In the period between the AMHP applying for the s.135(1) warrant 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(1) of the Mental Health Act (MHA) 1983 

AMHPs (who are usually specially trained social workers) are the only professionals authorised to apply to 
the Court for a warrant under section 135(1) MHA 1983.  

An application under section 135(1) is made where the AMHP has reason to believe that a person 
believed to be suffering from a mental disorder: 

•  Has been, or is being ill-treated, neglected or kept otherwise than under proper control, in any place 

within the jurisdiction of the justice, or 

•  Being unable to care for themselves, is living alone in any such place, 

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 If satisfied that any of the conditions above are met, a Magistrate may issue a warrant authorising any 
constable (who must be accompanied by an AMHP and a registered medical practitioner) to enter, if need 
be by force, any premises specified in the warrant in which that person is believed to be, and, if thought fit, 
to remove them to a place of safety. 

Executing a warrant obtained under section 135(1) MHA 1983 

After a warrant is obtained under section 135(1) MHA 1983 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, 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. The AMHP is then contacted to arrange a mutually convenient time and date 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 warrant authorises two legal powers for police officers: 

•  Entry to the premises, if need be by force 

•  Removal of the person concerned to a place of safety.  

The key responsibilities of the police when executing a s.135(1) MHA warrant are: 

1.  Entering the Premises -  

•  The police will enter the premises specified in the warrant and search the property to safely locate and 

contain the individual  

2.  Assist with Removal and Transport - 

• 

If the premises specified on the warrant is the individual’s home address of the AMHP/doctor may 
undertake the mental health assessment at the premises, provided that it is safe and appropriate to do 
so and they have the consent of the individual and any occupier. In such cases, there is no legal 
obligation for police to remain at the premises whilst the assessment takes place. However, police may 
remain at the premises if there is a risk posed to the AMHP/doctor or the individual; 

•  When an assessment is completed at the individual’s home address and a decision is made by 

healthcare professionals that inpatient admission is required, it is the responsibility of the AMHP to 
convey the individual to hospital and not the responsibility of police officers; 

•  However, if the police have removed the individual under the s.135(1) warrant in order for them to be 

taken to a place of safety, police will escort the person in the ambulance 

3.  Handover to Healthcare Professionals 

• 

If the police have removed the individual under the s.135(1) warrant, once at the place of safety, 
responsibility for the individual is transferred to mental health professionals. 

Timescale for execution of s.135(1) MHA warrants 

The Magistrate who grants the warrant will stipulate its 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.  

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In Mr Bainborough’s case, it was intended that the warrant be executed on 7 September 2023. This was 20 
days after the application for the warrant was made and eight days after the warrant was issued. Whilst 
there is no formalised fast-track procedure per se for the execution of s.135(1) warrants, high risk factors 
highlighted by the AMHP when requesting police assistance will be taken into account when researching, 
allocating resources and booking a date for the warrant to be executed to best protect those who are at risk 
of serious harm. 

Furthermore, 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. In an emergency, the AMHP can apply for a s.135(1) 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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