Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0248, written 28 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 May 2025 |
|---|---|
| Reference | 2025-0248 |
| Deceased | Dean Bradley |
| Coroner | Clare Bailey |
| Coroner area | Teesside and Hartlepool |
| Category | Suicide (from 2015) · Police related deaths |
| Organisation named | Tees, Esk and Wear Valleys NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 7 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
This document was classified as: OFFICIAL Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Department of Health and Social Care 2 Chief Executive of Integrated Care Board (NHS North East and North Cumbria) 3 Chief Executive of Tees Esk and Wear Valley NHS Mental Health Foundation Trust 4 Chief Executive of Middlesbrough Council 5 Chief Executive of Stockton Council 6 Chief Executive of Hartlepool Council 7 Chief Executive of Redcar Council 1 CORONER I am Clare BAILEY, Senior Coroner for the coroner area of Teesside and Hartlepool Coroner's Service 2 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. 3 INVESTIGATION and INQUEST Mr Dean Bradley died on 15th October 2021 at Tees. , Stockton on An inquest into Mr Bradley’s death was opened on 28th July 2023 and his inquest was heard before me on 19th May 2025. The medical cause of Mr Bradley’s death was: 1a. Pressure on the neck 1b. Hanging It was discovered in toxicology testing that the level of Venlafaxine in his blood was around twenty times that expected from a therapeutic dose and in the range associated with fatality. A narrative conclusion was given: “Dean Bradley hanged himself on the morning of 15th October 2021 in , Stockton on Tees whilst under the influence of excess amount of prescribed medication. The police failed to contact the mental health services when they assisted him at Thornaby station earlier in the day and failed to adequately relay details of his mental health crisis to staff at the hostel. The staff at the hostel failed to respond to information provided by the police. There were missed opportunities by both Cleveland Police and the hostel to involve mental health professionals and secure appropriate mental health support for Dean.” 4 CIRCUMSTANCES OF THE DEATH At approximately 0300 on 15th October 2021 Mr Bradley was found by the police walking on a dual carriageway. Following a discussion in which he revealed he was homeless the police secured emergency overnight housing for him at a hostel. There were no concerns for Mr Bradley’s mental health at that point. Regulation 28 – After Inquest Document Template Updated 30/07/2021 This document was classified as: OFFICIAL Mr Bradley was seen outside the hostel at 0450 and was met by the security officer. He spoke of people being after him. He was reassured and taken back to his flat. Mr Bradley left the hostel unwitnessed by the security officer. At 0540 a member of the public came across Mr Bradley sat on a bridge over a railway line. Mr Bradley stated he intended to kill himself. The member of the public spoke with Mr Bradley and called the police. During his time with the member of the public Mr Bradley moved himself as if to jump in front of a train when he thought a train was coming. The police attended. The police succeeded in bringing Mr Bradley down from the bridge and spoke with him in the police van. The officers came to the conclusion that Mr Bradley was under the influence of drugs. One of the officers raised concerns about Mr Bradley’s mental health as he was expressing persecutory beliefs and appeared paranoid and delusional. He believed that people were chasing him and wanted to kill him. The police considered contacting the Crisis Team and other mental health services but did not do so. The main reason for this is that, in their shared experience, the mental health services would tell them to safeguard Mr Bradley until he was sufficiently sober to be assessed. The police returned Mr Bradley to the hostel and, with the assistance of the security officer, Mr Bradley was shown CCTV of the premises. The purpose of showing Mr Bradley the CCTV was to prove no one was chasing him. Mr Bradley reportedly relaxed and accepted that no one was pursuing him. The police determined that the risk of suicide and self-harm had lessened and that it was safe and appropriate to leave Mr Bradley at the hostel. The police did not adequately relay the circumstances in which they found Mr Bradley to the security officer at the hostel. There was a brief comment that he was found sitting on the edge of a bridge at the station. The security officer did not enquire further. The security officer saw Mr Bradley leave his flat at approx. 0720. Mr Bradley refers to people being after him again. The security officer met with Mr Bradley, reassured him and took him back to his flat. Staff from the hostel knocked on Mr Bradley’s door at approx. 1015 as he had not left the flat. There was no response. Police attended and Mr Bradley as found deceased, hanging in his flat. The staff from the hostel were clear that the hostel was not a place for a person suffering from a mental health crisis. Residents are not checked upon, it is a service which provides accommodation only. Evidence was received from a Detective Chief Inspector who concurred. He also gave evidence as to Right Care Right Person initiative. He spoke of Crisis Cafes and Calming Centres in other regions where people who are under the influence of drugs or alcohol and present with metal health concerns may be supervised pending a mental health assessment. There appears to be a gap in the services available for people in this category. The officer spoke of a discussion with Middlesbrough County Council about provision of such a service. I stress that I did not make a causal link between Mr Bradley’s death and the unavailability of this resource. Neither the local authorities in this jurisdiction, the Integrated Care Board (NHS North East & North Cumbria), Tees Esk and Wear Valley NHS Mental Health Foundation Trust nor the Department of Health were Interested Persons in the inquest. They did not give evidence at the inquest as the concerns raised did not come to light until the hearing. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. Regulation 28 – After Inquest Document Template Updated 30/07/2021 This document was classified as: OFFICIAL The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk. 2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 23, 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Watson Woodhouse – Legal representative for Mr Bradley’s family I have also sent it to Cleveland Police New Walk CIC who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 28/05/2025 Clare BAILEY Senior Coroner for Teesside and Hartlepool Coroner's Service Regulation 28 – After Inquest Document Template Updated 30/07/2021 This document was classified as: OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021
7 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.
From Parliamentary Under Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 020 7210 4850 Our Ref: HM Senior Coroner Clare Bailey Teesside and Hartlepool Coroner's Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ 18 August 2025 Dear Ms Bailey, Thank you for your Regulation 28 report to prevent future deaths dated 28 May 2025 about the death of Dean Bradley. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Bradley’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. I have noted the contents of your report, and the matters of concern raised. In response, I have liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding to you directly. The ICB has advised that it commissions a 24/7 mental health crisis assessment suite based on the Roseberry Park Hospital site in Middlesbrough, alongside a dedicated mental health crisis response and home treatment team. These services provide timely assessment, support and intervention to individuals in crisis, including individuals who may be unable to participate in an assessment due to their level of intoxication. The crisis assessment suite and the crisis team were available and fully operational at the time of Mr Bradley’s death but were not contacted during the events leading to his death. The ICB has also advised that, while clinical judgement will always factor in a person’s level of intoxication, this is not a barrier to initial engagement, and there is no blanket rule preventing assessment while a person is intoxicated. Your report also mentions Right Care, Right Person (RCRP). As you may be aware, this is a police-led initiative that is being rolled out nationally to reduce police time spent on health and social care related incidents, with a particular focus on mental health. At the centre of the RCRP approach is a threshold to assist police in making decisions about when it is appropriate for them to respond to incidents which relate to people with mental health needs. Under RCRP, police will continue to be involved in incidents where there is a real and immediate risk to life or serious harm or responding to a report of crime. To minimise delays to handovers of care between the police and mental health services, local areas should be working towards handovers taking place within one hour from arrival at an appropriate health setting (unless mutually agreed in relation to a particular incident on a case-by-case basis). An Oversight Group has been set up by the Home Office and Department of Health and Social Care (DHSC), in partnership with NHS England (NHSE) and the National Police Chiefs’ Council (NPCC), in order to provide a national level forum to regularly review any concerns/issues with RCRP implementation. I understand that Cleveland Police began to implement this approach in 2024, so while it would not have been relevant to this case, it should be helpful in assisting Cleveland Police, working in partnership with the NHS locally, in making decisions about responses to future incidents relating to people with mental health needs. information on Right Care Right Person Further https://www.gov.uk/government/publications/national-partnership-agreement- rightcare-right-person/national-partnership-agreement-right-care-right-person-rcrp is available at: We are also committing £26 million in capital investment to support people in mental health crisis, including opening new mental health crisis centres, which aim to provide accessible and responsive care for individuals in mental health crisis. This builds on the hundreds of alternative crisis services, including crisis cafes, sanctuaries and crisis houses, put in place in recent years, that provide supportive environments outside of traditional clinical settings, and 33 new or improved health-based places of safety. I hope this response is helpful. Thank you for bringing these concerns to my attention. All good wishes,
CLASSIFICATION – Confidential Tel: www.hartlepool.gov.uk Our Ref: Your Ref: , Executive Director Adult and Community Based Services Civic Centre Hartlepool TS24 8AY Contact Officer: Email: 23 June 2025 Clare Bailey Senior Coroner Teesside and Hartlepool Coroner’s Service (by email) Dear Ms Bailey Regulation 28 Report: Dean Bradley I write in response to the Regulation 28 report dated 28 May 2025 regarding the death of Dean Bradley in the Stockton area in October 2021, which highlighted concerns in relation to resources for safeguarding those with mental health illnesses whilst intoxicated and how a person who was suicidal, suffering with mental health concerns and intoxicated could be adequately safeguarded until sufficiently sober to allow a mental health assessment. I can confirm that I raised these issues with the Independent Chair of the Teeswide Safeguarding Adults Board (TSAB) following receipt of the Regulation 28 Report, and the matters of concern were subsequently discussed at a meeting of the Board on 11 June 2025. Following that discussion I can confirm that, while there is not a ‘Crisis Café’ provided within the Tees area, such a provision would not have been appropriate for an individual presenting as Mr Bradley did. The appropriate place for him to have been supported at the time of the incident in 2021 was the assessment suite at Roseberry Park which is designated as a place of safety under Section 136 of the Mental Health Act, and this remains the case at the present time. This service is provided by Tees Esk & Wear Valleys NHS Foundation Trust and their policy relating to Section 136 (which is available on their website and is attached for reference) clearly identifies that this provision is appropriate for an individual who is intoxicated but not presenting with immediate physical health risks. If there are immediate risks to physical health, the appropriate place of safety would be a hospital emergency department. There is a Multi Agency Mental Health Legislation Operational Group where this policy and related issues are shared and, through this route, consideration will be given to whether there is a need for further education and awareness raising within Cleveland Police regarding the use of Section 136 powers to safeguard an individual requiring mental health assessment. CLASSIFICATION – Confidential I will take this opportunity to recirculate the Section 136 Policy to relevant staff within Adult Social Care in Hartlepool Borough Council, and to make them aware of the concerns identified through Mr Bradley’s inquest. Yours sincerely Executive Director of Adult and Community Based Services c.c. , Managing Director , Independent Chair of TSAB
NENC ICB Pemberton House Colima Avenue Sunderland SR5 3XB 02 July 2025 Strictly Confidential Miss Clare Bailey Senior Coroner Teesside and Hartlepool Coroner's Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ Dear Miss Bailey Mr Dean Bradley I write in response to your Regulation 28 Report to Prevent Future Deaths, dated 28 May 2025, concerning the death of Mr Dean Bradley. Firstly, I would like to extend my sincere condolences to Mr Bradley's family and loved ones. We have noted the contents of the report, and the matters of concern raised requiring a response from NHS North East and Cumbria Integrated Care Board (NENC ICB), as follows: 1) Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk. In Teesside, the NENC ICB commissions a 24/7 mental health crisis assessment suite based on the Roseberry Park Hospital site in Middlesbrough, alongside a dedicated mental health crisis response and home treatment team. These services are in place to provide timely assessment, support and intervention to individuals in crisis. We note the reference in the report to the crisis team, however, as they were not contacted by the police in Mr Bradley's case, we are unable to comment on what response might have been elicited. However, the ICB would expect the crisis team to respond to such a request and that an assessment would have been attempted. Similarly, had the individual presented to the crisis assessment suite accompanied by police, an assessment would have commenced. In circumstances where an individual is unable to participate in an assessment due to their level of intoxication, the clinical team will make a plan to complete the assessment at the earliest opportunity, taking into account the person's presentation and any immediate risks. If the individual is presenting as violent or aggressive, a request may be made to the police to remain present during the assessment, to ensure the safety of all involved. The crisis assessment suite and the crisis team have been in place in Teesside for many years and were available and fully operational at the time of Mr Bradleys tragic death. Cleveland Police were involved in the development of the crisis assessment suite from its inception, and we value their ongoing collaboration. However, as mental health services were not contacted during the events leading to Mr Bradley’s death, we are unable to determine whether their involvement might have altered the outcome. 2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment We understand that police officers considered contacting the crisis team but did not do so, based on their experience that services may not assess a person until they are sufficiently sober. While clinical judgement will always factor in a person’s level of intoxication, this is not a barrier to initial engagement. Referrals are received regularly for individuals with varying levels of intoxication, and risk is assessed on a case-by-case basis. There is no blanket rule preventing assessment while a person is intoxicated. The crisis service will undertake specific alcohol and drug use assessments in all cases in order to inform care, treatment and ongoing support planning an individual may require, in relation to both their mental health and any coexisting substance use. The NENC ICB has no plans to develop a specific holding facility for intoxicated individuals awaiting assessment. We continue to work closely with mental health providers and partners, including the police, to ensure our crisis services remain responsive. We remain committed to reducing risk and improving pathways of care for individuals in mental health crisis. I hope this response addresses the concerns outlined in your report. Please do not hesitate to contact me should you require any further information. Yours sincerely, Executive Medical Director North East and North Cumbria ICB
This document was classified as: OFFICIAL Director of Adult Social Care and Health Integration Email: Claire Bailey Senior Coroner Teesside & Hartlepool Coroners Service By email Dear Ms Bailey Re: Regulation 28 Report : Dean Bradley 18th July 20205 I am writing in regard to the above report dated 28 May 2025, concerning the death of Dean Bradley within the Stockton area on 15th October 2021. The report highlighted concerns in relation to current resources for safeguarding those with mental health illness whilst intoxicated, and furthermore how an induvial whom is intoxicated with a mental illness and exhibiting suicidal tendencies is safeguarded until the appropriate time to undertake a mental health assessment. This enquiry has been discussed at strategic board level within the Teeswide Safeguarding Adults Board (TSAB) on the 11th June 2025. The conclusion from these muti-agency discussions identified, that whilst within the Tees area we do not currently have a “crisis café”, we do have some designated safe spaces, however in the circumstances outlined these would not be an appropriate response. It was agreed that the most appropriate action at the time of the incident, and also relevant now, would have been a presentation to the assessment suite at Roseberry Park, which is a designated place of safety under Section 136 of the Mental Health Act. I understand my colleague from Hartlepool Council has sent through the relevant policy guidance in regard to this provision. The service is provided by Tees Esk & Wear Valley Trust, and confirmation has been sought that this provision is appropriate for an individual who is intoxicated but not presenting with any immediate physical health concerns. Therefore in light of the report received I can confirm that this has been discussed at the Teeswide Safeguarding Board which concluded local provision is in place, I furthermore also commit to ensuring my own mental health service received refreshed communication with regard to section136 guidance, and the circumstances relating to the Regulation 28 report. This will be actioned with immediate effect. In addition this will also be flagged within the Multi-Agency Mental Health Legislation Middlesbrough Council, PO Box 500, Middlesbrough, TS1 9FT middlesbrough.gov.uk This document was classified as: OFFICIAL Operational Group to determine the need for further awareness and training roll out among our wider partners. Yours sincerely Director of Adult Social Care & Health Integration
Redcar & Cleveland Borough Council Directorate of Adults and Communities Redcar & Cleveland House Kirkleatham Street Redcar Yorkshire TS10 1RR Our Ref: Contact: Direct line: 21 July 2025 Dear Ms Bailey, Regulation 28 Report: Dean Bradley I write on behalf of Redcar and Cleveland Borough Council in response to the Regulation 28 report dated 28 May 2025 regarding the death of Dean Bradley in the Stockton area in October 2021. This highlighted concerns in relation to resources for safeguarding those with mental health illnesses whilst intoxicated and how a person who was suicidal, suffering with mental health concerns and intoxicated could be adequately safeguarded until sufficiently sober to allow a mental health assessment. These issues were raised with the Independent Chair of the Teeswide Safeguarding Adults Board (TSAB) following receipt of the Regulation 28 Report, and that the matters of concern were subsequently discussed at a meeting of the Board on 11 June 2025. Following that discussion there was an agreed view that, while there is not a ‘Crisis Café’ provided within the Tees area, such a provision would not have been appropriate for an individual presenting as Mr Bradley did. The appropriate place for him to have been supported at the time of the incident in 2021 was the Crisis Assessment Suite at Roseberry Park which is designated as a place of safety for Police to use under Section 136 of the Mental Health Act, and this remains the case at the present time. This service is provided by Tees Esk & Wear Valleys NHS Foundation Trust and their policy relating to Section 136 clearly identifies that this provision is appropriate for an individual who is intoxicated but not presenting with immediate physical health risks. An alternative if the individual was incapacitated, would be the Hospital Emergency Department, however in Mr Bradley’s case the Crisis Assessment Suite would have been most appropriate. A Multi Agency Mental Health Legislation Operational Group meeting was held on the 11th of July where this policy and related issues were discussed. Cleveland Police was present at this meeting and will continue to raise awareness with Police colleagues regarding the use of Section 136 powers to safeguard an individual requiring mental health assessment. The Council will take this opportunity to recirculate the Section 136 Policy to relevant staff within Adult Social Care in Redcar & Cleveland Adult Social Care and to make them aware of the concerns identified through Mr Bradley’s inquest. We will commence this process immediately. I trust that this response meets your requirements but please let me know if you require any further information or clarification of the points set out above. Yours sincerely, Executive Director, Adults & Communities
This document was classified as: OFFICIAL My Ref: Your Ref: Dunedin House Columbia Drive Thornaby Stockton-on-Tees TS17 6BJ Tel: 01642 526156 Date: 14 July 2025 Email: Dear Ms Bailey Regulation 28 Report: Dean Bradley Thank you for the Regulation 28 Report dated 28 May 2025 regarding the death of Dean Bradley in October 2021 which you sent to , Chief Executive. The report highlighted concerns in relation to resources for safeguarding those with mental health illnesses whilst intoxicated and how a person who was suicidal, suffering with mental health concerns and intoxicated could be adequately safeguarded until sufficiently sober to allow a mental health assessment. It was noted that the Regulation 28 Report was sent to the four Local Authorities in the area. I am aware that the matters for concern were raised with the Independent Chair of the Teesside Safeguarding Adults Board (TSAB) and were discussed at a meeting of the Board on 11 June 2025. It is noted that the evidence heard during the Inquest was that an intoxicated person could not be adequately safeguarded until they were sufficiently sober to allow a mental health assessment leading to the conclusion of there being a gap in services available. In our view, the most appropriate approach to dealing with Mr Bradley at his time of crisis would have been for the Police Officers to detain him under Section 136 of the Mental Health Act and take him to a place of safety. Section 136 of the Mental Health Act is a critical legal framework that enables Police Officers to act in situations where individuals may be at risk due to mental health issues. This power allows the detention of individuals appearing to have a mental disorder who are in a public place. When the Police attended, Mr Bradley was sitting on the bridge over the railway line, he was in a public place, and it is relayed in the Regulation 28 Report that Mr Bradley was having persecutory beliefs and paranoia saying he wanted to kill himself. This meets the criteria of the S136 power and therefore the most appropriate action would have been to detain Mr Bradley under that power and take him to the assessment suite. Clare Bailey Senior Coroner Teesside & Hartlepool Coroners Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ This document was classified as: OFFICIAL The assessment suite is in Roseberry Park Hospital. Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) run this hospital. This is the designated place of safety for those under the influence of drugs or alcohol and presenting with mental health concerns. Under the S136 power, the individual can be held for up to 24 hours, extendable by an additional 12 hours if necessary for assessment. During this time, mental health professionals would assess an individual to determine their needs and whether further treatment is required. The region does not have ‘crisis cafes’ or ‘Calming Centres,’ but the assessment suite is deemed to be a service that works well when used by the Police. Representatives from Stockton Borough Council sit on a Mental Health Legislation Operational Group. It is proposed that TEWV’s policy on Section 136 is brought to this group to consider whether there is a need for further education and awareness within Cleveland Police regarding the use of Section 136 powers to safeguard an individual requiring mental health assessment. I will also recirculate the Section 136 Policy to relevant staff within Adult Social Care in Stockton Borough Council raise awareness of the concerns identified through Mr Bradley’s inquest. Yours sincerely Interim Director Adults Social Care
Chief Executives Office West Park Hospital Edward Pease Way Darlington DL2 2TS Tel: 0191 333 6533 www.tewv.nhs.uk 22 July 2025 Email: To: Claire Bailey Senior Coroner for Teesside and Hartlepool Coroner’s Service His Majesty's Coroner for Teesside The Coroner's Service Middlesbrough Town Hall Albert Road Middlesbrough TS1 2QJ Re: Regulation 28 Report to Prevent Future Deaths - Mr Dean Bradley Dear Ms Bailey, Thank you for your Report to Prevent Future Deaths (Regulation 28) dated 28/05/2025, following the inquest into the death of Mr Dean Bradley. We acknowledge the findings and concerns raised in your report. We take your concerns extremely seriously and are committed to taking appropriate actions to address any issues and reduce the risk of deaths in similar circumstance and ensure organisational learning from this tragic event to prevent future deaths. Brief description of the incident wherefrom the concerns arise taken from Regulation 28 report: Mr Bradley was seen by the police on two occasions on the morning of his death. On the first occasion there were no concerns about his mental health, but he was homeless, and the Police secured him emergency accommodation. On the second occasion he had left his emergency accommodation, police were alerted to his presence on a bridge by a member of the public, and he was thought to have paranoid beliefs of people chasing him and wanting to kill him and expressed he intended to kill himself. The officers came to the conclusion that he was under the influence of drugs. The police considered contacting the Crisis Team and other mental health services but did not do so as they reported that in their shared experience Mental Health services would tell them to safeguard him until he was sufficiently sober to be assessed. He was returned to the hostel. Interim Chief Executive: Interim Chair: 1 The Detective Chief inspector gave evidence as to Right Care Right Person initiative. He spoke of Crisis Cafes and Calming Centres in other regions where people who are under the influence of drugs or alcohol and present with mental health concerns may be supervised pending a mental health assessment. There appears to be a gap in the services available for people in this category. The officer spoke of a discussion with Middlesbrough County Council about provision of such a service. Concern 1 Current resources for safeguarding those with mental health illnesses whilst intoxicated may be placing people at risk. Within TEWV we provide health-based places of safety (HBPOS) across the Trust including in Middlesborough, and we did so at the time of this incident. These are used by the police to bring people they have concerns about under Section 136 of the Mental Health Act (MHA) 1983 to enable assessment by appropriately trained Mental Health Professionals. This would be the case even if the person is intoxicated or under the influence of substances but with no suspected physical risk. Concern 2 I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment. The police have the option, based on their contact with the person, to detain the person under Section 136 of the Mental Health Act (MHA) 1983 and bring them to a Health Based Place of Safety (HBPOS) which for Teesside is located in Roseberry Park Hospital, Middlesbrough adjacent to the Crisis Assessment Suite. Had the police contacted the Crisis Service they would have been advised that this was the appropriate course of action in these circumstances. If there is a physical health related issue in addition to mental health issues such as an overdose of medication, the Police may transport the person to A&E first and Psychiatric Liaison Service may be called upon later, once the person is physically stable. In the last quarter of 2024, the police brought people to a HBPOS in TEWV on 230 occasions, 73 of which were to the Middlesbrough HBPOS. In 2021, there were 531 uses of S136 MHA across the Trust. Section 136 of the Mental Health Act (MHA) 1983 is an emergency police power which allows for the removal of a person, without warrant, from any place other than a private dwelling, if the person appears to a police officer to be suffering from mental disorder and to be in immediate need of care or control, if the police officer believes it necessary in the interests of that person, or for the protection of others. The person will then receive a mental health assessment, and any necessary arrangements will be made for their on-going care and/or treatment. Section 136 MHA and the Trust’s Section 136 Policy outlines that individuals detained under Section 136 MHA must be assessed by a Registered Medical Practitioner (RMP) and an Approved Mental Health Professional (AMHP) as soon as possible, ideally commencing within 3 hours of Interim Chief Executive: Interim Chair: 2 arrival at the Place of Safety. However, the policy allows for clinical discretion to delay assessment if intoxication impairs the person’s ability to engage meaningfully. The assessment must be safe, and the person must be physically stable before proceeding. Crisis clinicians use the Alcohol intoxication assessment to ensure the individual is able to take part in a mental health assessment in a meaningful way. Even if a Crisis Café or Calming Centre had been available, given the person’s expressions of suicidal intent and potential paranoid ideation and the fact that a person can just leave these premises, it would be unlikely that it would have been appropriate to take him to such a provision. Organisational Learning The Trust host regular Muti-Agency Mental Health Legislation Operational Groups where partner agencies and organisations, including the police, meet to discuss operational issues and to try to resolve issues that may have arisen and to identify areas of best practice. We have shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025. This enabled us to ensure that the police are aware of the Report and the issues of concern that you have raised and to identify and re-iterate best practice in this, or any similar, scenarios. This report has also been shared with Crisis Teams. Conclusion We would like to express our condolences to the family and friends of the deceased. We are committed to ensuring that learning from this tragic event ensues and grateful for the opportunity to reflect and improve. Please do not hesitate to contact us should you require further information. Yours sincerely Chief Nurse & Interim Chief Executive Interim Chief Executive: Interim Chair: 3
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