Concerns raised 6 Ineffective and insufficiently repeated mental health training for police officers View source Failure to share all relevant information with mental health practitioners in a timely manner View source Lack of joint training between police and mental health services on information sharing View source Lack of defined information-sharing arrangements for the Rapid Response Service View source Failure to ensure police officers understand mental health issues and referral information requirements View source Lack of mandatory mental health training for existing officers and rollout of accredited training for new officers View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ryan Louis Ouslem · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective and insufficiently repeated mental health training for police officers
Wider context from the report “Sussex police were afforded the opportunity to provide information about their training provision after the inquest. I have considered this information and I still have concerns. The police have stated that mental health training has been a particular focus for some time. Despite this an officer with a training role was unable to explain what training that was and when they had received it.
It appears to me from the police response that whilst mental health training and resources are offered to existing officers it is still not mandatory. I note that new officers joining will be undergoing accredited mental health training but this has not yet been rolled out.
Whatever training and resources have been provided I remain concerned it has not been effective and is not repeated as often as may be required to provide officers with the necessary skills and knowledge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share all relevant information with mental health practitioners in a timely manner
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner .
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of joint training between police and mental health services on information sharing
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned . I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of defined information-sharing arrangements for the Rapid Response Service
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out . Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police officers understand mental health issues and referral information requirements
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide .
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory mental health training for existing officers and rollout of accredited training for new officers
Wider context from the report “Sussex police were afforded the opportunity to provide information about their training provision after the inquest. I have considered this information and I still have concerns. The police have stated that mental health training has been a particular focus for some time. Despite this an officer with a training role was unable to explain what training that was and when they had received it.
It appears to me from the police response that whilst mental health training and resources are offered to existing officers it is still not mandatory . I note that new officers joining will be undergoing accredited mental health training but this has not yet been rolled out .
Whatever training and resources have been provided I remain concerned it has not been effective and is not repeated as often as may be required to provide officers with the necessary skills and knowledge.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the LEARN learning management system to record all officers’ training and support compliance follow-up for missed or incomplete courses.
Verbatim wording from the response “Going forwards, we are expanding the roll out of our LEARN platform, our new learning management system. Currently, all training attended by new recruits is recorded to ensure they complete necessary modules. This is now being expanded to record and capture all training to all officers, allowing us to review completion and missed courses more effectively.” Source location Response from Sussex Police 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce mandatory Mental Health First Aider training for all new recruits as part of induction.
Verbatim wording from the response “In addition to the training currently outlined by ████████ we are also introducing, from January 2025, Mental Health First Aider training to all new recruits. This is comprehensive and consists of a number of packages that will be delivered as part of their induction course which is bespoke to their future role. Attendance is mandatory.” Source location Response from Sussex Police 2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a detailed mental health presentation as additional refresher training for officers.
Verbatim wording from the response “Most recently, and going forwards, a detailed presentation has been included which covers poor mental health and the complexities faced by officers, serving as additional refresher training (appendix 6).” Source location Response from Sussex Police 2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out mandatory “Mental Health and the Police” e-learning to specified officers and staff, recording completion and monitoring compliance.
Verbatim wording from the response “Work continues with the Sussex Police Learning & Professional Development Team (L&PD) to roll out a mandated training package via the College Learn Training Platform. As referenced in Mr Gordon’s statement, “Mental Health and the Police” is a 90-minute e-learning package produced by the College of Policing. It was initially rolled out to Response Officers in Winter 2021, and Autumn of 2022, but completion will now be mandatory for the following officers and staff:” Source location Response from Sussex Police 1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a two-day accredited mental health course for new officers and offer additional places to longer-serving officers.
Verbatim wording from the response “Moving forwards, all new Police officers joining Sussex Police via initial entry routes will be completing a two-day mental health course, which is an accredited qualification – “Level 3 in Supervision of Mental Health”. The anticipated rollout is from January 2025 and the qualification will give officers the opportunity to spend more time on the techniques of talking to people presenting with a mental health condition and will involve completion of related scenarios.” Source location Response from Sussex Police 1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mental health training through existing force-wide training programmes.
Verbatim wording from the response “Mental Health Training at Sussex Police” Source location Response from Sussex Police 1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer Divisional Coaching Unit staff into Neighbourhood Policing Teams so their mandatory training aligns with those teams.
Verbatim wording from the response “It is however accepted that currently, PC ████████’s role in the Divisional Coaching Unit (DCU) does not necessarily capture all CPD Training and Professional Development Days, as her role is not classed as a Response Officer nor Neighbourhood Policing Officer, for whom training is mandated. Officers within the DCU can attend CPD Training but is dependent on their awareness that the CPD sessions are being run.” Source location Response from Sussex Police 1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Joint training with SPFT is not considered workable because its cost and logistical requirements are disproportionate at this stage.
Verbatim wording from the response “We have carefully considered whether joint training with SPFT could provide anything additional which could assist officers when referring matters and providing information to them, however we do not believe it is workable step and the cost and logistics of doing so would not be proportionate at this stage.” Source location Response from Sussex Police 2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The operational Blue Light Line and existing policy are sufficient; police officers will not need to change practice when Rapid Response launches.
Verbatim wording from the response “As it stands, the Rapid Assessment Service or Rapid Response will be accessed by our officers via the Blue Light Line. The Blue Light Line is already operational, and it is current policy to utilise this service when dealing with a mental health incident. The Blue Light Line retains records of the contact and ensures information is correctly processed. There will be no change in practice required for police officers when the Rapid Response Service is launched, and it anticipated it will enhance the offer of service from the Blue Light Line.” Source location Response from Sussex Police 1
Open published response
Concerns raised 12 Failure to provide formal written LDS mental health assessments to police View source Lack of a documented LDS mental health plan for custody View source Unavailability of appropriate LDS-police liaison templates View source Lack of local or national procedures for obtaining mental health assessments during intoxication View source Difficulty obtaining collateral mental health information from other services View source Failure of LDS and police information sharing about custody mental health presentation View source Unavailability of a 24-hour LDS service in custody View source Lack of formal police documentation of family concerns about mental health deterioration View source Lack of formal written handovers of mental health presentation between police officers View source Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals View source Lack of formal documentation procedures for LDS and police custody care View source Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miles Ethan Hurley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written LDS mental health assessments to police
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented LDS mental health plan for custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody .
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriate LDS-police liaison templates
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of local or national procedures for obtaining mental health assessments during intoxication
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated , a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24-hour LDS service in custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written handovers of mental health presentation between police officers
Wider context from the report “1. Lack of effective Communication between police officers
The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers , complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal documentation procedures for LDS and police custody care
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures , or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and regularly review detainee risk assessments and care plans, recording changing physical or mental health information and responding to identified risks.
Verbatim wording from the response “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review operating procedures and guidance for mental-health assessment of intoxicated detainees and use national guidance rather than a separate memorandum of understanding.
Verbatim wording from the response “We have reviewed the current operating procedures and guidelines regarding when to obtain a mental health assessment if the individual is intoxicated, and the following provides the process and/or gives guidance to Sussex Police:” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add information received from detainees’ families to the custody care plan so concerns are formally recorded and addressed.
Verbatim wording from the response “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record custody risks and concerns discussed with Liaison and Diversion staff on the detainee’s risk assessment and care plan.
Verbatim wording from the response “LDS Nurses will proactively triage detainees listed on the Custody White Board between 08:00hrs and 20:00hrs. This is a virtual white board accessed via NICHE which LDS nurses can independently access at any time. It contains details of all detainees in each Custody Centre. A Professional Discussion will be held between the LDS Nurse and Principal Sergeants to identify assessments that may need to be prioritised.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply established clinical-escalation procedures, including requesting healthcare assessment when release presents a wellbeing risk or a detainee’s health changes.
Verbatim wording from the response “If we consider their release to present a risk to their wellbeing, then we will ask the HCP to complete a Fit to Release Risk Assessment. The request is made where the physical or mental health of a detainee has changed. MITIE Healthcare are contracted to complete the Fit to Release Risk Assessment. In that risk assessment detention under S136 Mental Health Act 1983 may be considered.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain documented, verbally delivered and CCTV-recorded custody handovers, with live risk updates, shared access, audit trails, staff training and peer review.
Verbatim wording from the response “At the point of handover, the Principal Sergeant will refer to a handover document (a copy of which is supplied at Appendix 1) from which they will brief the oncoming team verbally. All members of the current duty team and the oncoming team will be present. They are each given a copy of the handover document which they can refer to during the briefing. The briefing is delivered by the Principal Custody Sergeant in person and is recorded on CCTV which is accessible at any time.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinically trained professionals, rather than police officers, should make healthcare decisions concerning detainees.
Verbatim wording from the response “The APP guidance is therefore clear that:” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A memorandum of understanding is unnecessary because existing national guidance already codifies custody risk assessment and healthcare procedures.
Verbatim wording from the response “The APP guidance is therefore clear that:” Source location Response from Sussex Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support development of a national FEO curriculum and learning outcomes aligned with quality assurance and mandatory professional development.
Verbatim wording from the response “Sussex Police have been supporting the national NPCC lead and the College of Policing over the past 12 months in developing a national curriculum and learning outcomes for Firearms Enquiry Officers. The intention is that the training will be delivered this year, which will be aligned with quality assurance and mandatory professional development. Sussex Police FELU will be active participants at the two day CPD event hosted by the College of Policing in May 2023. This will enable critical learning from the detailed de-brief of the lessons from the Keyham Shootings Inquests and the new Home Office Statutory Guidance.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh all FELU staff training on the revised February 2023 Home Office Statutory Guidance through continuing professional development.
Verbatim wording from the response “A schedule of additional training is also being delivered this year to supplement the external training. This will cover issues relating to safeguarding, intelligence gathering, application of the National Decision Making Model and the safe handling of firearms. The work that has been developed has been recognised by an external audit carried out by the Southern Internal Audit Partnership (SIAP) with its final report due to be released imminently. All staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of the revised guidance February 2023, this has been updated and refreshed for all FELU staff as part of their continuous professional development.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a bespoke firearms licensing course for Sussex Police FEOs and supervisors through the existing provider.
Verbatim wording from the response “In the absence of any national training product accredited by the College of Policing, all Sussex Police Firearms Enquiry Officers (FEOs) and supervisors have attended a firearms licensing course that is designed and delivered in Yorkshire. This has only resumed this year due to the impact of Covid and as such some recent joiners into the department have not yet attended. However, we have commissioned a bespoke course with the same provider exclusively for Sussex Police which is scheduled for May 2023. There is currently no nationally available course for office based Firearms Registration Officers (FRO) however this training is internally delivered and managed by the office supervisor.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver additional training on safeguarding, intelligence gathering, the National Decision Making Model and safe firearms handling.
Verbatim wording from the response “A schedule of additional training is also being delivered this year to supplement the external training. This will cover issues relating to safeguarding, intelligence gathering, application of the National Decision Making Model and the safe handling of firearms. The work that has been developed has been recognised by an external audit carried out by the Southern Internal Audit Partnership (SIAP) with its final report due to be released imminently. All staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of the revised guidance February 2023, this has been updated and refreshed for all FELU staff as part of their continuous professional development.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing and continuing training is considered appropriate and proportionate to staff roles within the firearms licensing unit.
Verbatim wording from the response “I am satisfied that based on the information available to me, that all staff have received and will be continuing to receive appropriate training, proportionate to their respective roles within the Sussex Police FELU.” Source location Response from Sussex Police
Open published response
28 Oct 2022 Jade Hutchings · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Lack of REBOOT provision for older children nearing 18 View source Failure of police officers to read the mental health guide in full View source Inadequate police mental health training View source Confusion among police officers about the provision and use of the Haven at Millview service View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Enhance and update initial mental-health training for all new officers, including legal powers, vulnerability, equality and cultural influences.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Deliver mental-health training to all control-room operators, including guidance on mental-health-related calls and Section 136 detentions.
Stated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Deliver mental-health content through mandatory personal-safety, inspector and custody-officer training, including crisis recognition, de-escalation and Section 136 procedures.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Deliver mandatory mental-health continuing professional development, including College of Policing e-learning and related legislation, incident-response and suicide-response modules.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Publish and add a concise Section 136 detention and Blue Light Line guide to the Crewmate application for frontline officer reference.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Develop and deliver mental-health and policing training under oversight from a mental-health social worker and in line with College of Policing guidance.
Stated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source See 3 more actions
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AI-generated summary
Jade Hutchings · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jade Hutchings, who was 18, had been struggling with his mental health and using alcohol and drugs. After going missing while under their influence, he was found hanging at home and died in hospital on 23 May 2020. Concerns included inadequate police mental-health training and a lack of early-intervention provision for older children through the REBOOT scheme.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of REBOOT provision for older children nearing 18
Wider context from the report “2. REBOOT - Lack of provision for older age group
There was clear evidence that Jade was vulnerable and had become involved in violence and crime in 2019 (the year before his death). It was believed by some that Jade exploited by gangs running county line drug operations. A need for an early intervention was identified by his social worker and a referral to Reboot was made.
The Inquest was told that at the time REBOOT was prioritising 12 – 14 years children and as Jade was nearing 18 they were unable to work with him . This was a missed opportunity for Jade to be involved in a form of early intervention before his life started unravelling and he became more heavily entrenched in the world of crime.
It is understood that at the time of Jade’s death the Police and Crime Commissioner was responsible for the REBOOT scheme but at the time of writing this report the scheme is now run by Sussex Police.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police officers to read the mental health guide in full
Wider context from the report “1. Inadequate Police training on Mental Health
During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training. Some officers could not recall any additional training provided since their initial training when they first joined the force.
The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full .
The expert police witness, ████████, told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient. None of the officers involved in this case had yet undertaken this online training.
It was his opinion that officers should be provided with the nationally recognised two day training course written by the College of Policing, The course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police.
There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate police mental health training
Wider context from the report “1. Inadequate Police training on Mental Health
During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training . Some officers could not recall any additional training provided since their initial training when they first joined the force .
The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full.
The expert police witness, ████████, told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient . None of the officers involved in this case had yet undertaken this online training .
It was his opinion that officers should be provided with the nationally recognised two day training course written by the College of Policing, The course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police .
There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Confusion among police officers about the provision and use of the Haven at Millview service
Wider context from the report “1. Inadequate Police training on Mental Health
During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training. Some officers could not recall any additional training provided since their initial training when they first joined the force.
The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full.
The expert police witness, ████████, told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient. None of the officers involved in this case had yet undertaken this online training.
It was his opinion that officers should be provided with the nationally recognised two day training course written by the College of Policing, The course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police.
There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance and update initial mental-health training for all new officers, including legal powers, vulnerability, equality and cultural influences.
Verbatim wording from the response “Mental health training is provided to all Student Officers in Sussex during their initial training programme. In December 2020 the initial training package was enhanced and again updated in March 2022. The training being delivered to all new officers joining Sussex Police at the time of writing (December 2022) is set out below.” Source location Response from Sussex Police 21.12
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mental-health training to all control-room operators, including guidance on mental-health-related calls and Section 136 detentions.
Verbatim wording from the response “Current courses now include a mental health training input on the following mandatory courses:” Source location Response from Sussex Police 21.12
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mental-health content through mandatory personal-safety, inspector and custody-officer training, including crisis recognition, de-escalation and Section 136 procedures.
Verbatim wording from the response “Personal Safety Training” Source location Response from Sussex Police 21.12
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory mental-health continuing professional development, including College of Policing e-learning and related legislation, incident-response and suicide-response modules.
Verbatim wording from the response “1. The College of Policing e-learning module. – Mental Health and the Police
This module has already been included in our CPD programme and all response officers must have completed this as part of the CPD schedule in 2022.” Source location Response from Sussex Police 21.12
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and add a concise Section 136 detention and Blue Light Line guide to the Crewmate application for frontline officer reference.
Verbatim wording from the response “We understand this observation to relate to the wider context of the ‘Blue Light Line’ (of which the Haven at Millview forms part), the telephone provision provided by Sussex Partnership NHS Foundation Trust for officers to use for consultation about mental health incidents, namely when they are considering using their powers under s136 of the Mental Health Act (1983).” Source location Response from Sussex Police 21.12
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver mental-health and policing training under oversight from a mental-health social worker and in line with College of Policing guidance.
Verbatim wording from the response “All training that is delivered by Sussex Police on Mental Health & Policing is in line with the College of Policing’s APP on Mental Health & Policing and is currently developed and delivered with oversight from a mental health social worker.” Source location Response from Sussex Police 21.12
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College of Policing does not deliver the purported two-day classroom course, and forces have discretion over which programme elements officers undertake.
Verbatim wording from the response “The comments and concerns of the Expert Police Witness, ████████ in relation to Sussex officers undertaking the College of Policing (CoP) two-day training course, have been carefully considered. The College of Policing do not deliver a two-day classroom-based learning course but do offer a ‘Mental Health Programme’ (published in October 2021) intended to support the Police Service to develop and deliver their own ‘in house’ training programme. The College of Policing recommend a ‘target audience’ for each module of their Mental Health Programme and individual forces are given discretion as to who would be more appropriate to attend specific parts of the programme; for example, the target audience for developing a strategic response to mental health is aimed at Inspectors and above up to and including NPCC and police staff equivalent.” Source location Response from Sussex Police 21.12
Open published response
28 Jan 2022 Jack Stephen TAYLOR · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Mismatch between AWOL and missing-person risk assessment grading criteria View source Unavailability of patient transport for absconding-patient returns View source Inadequate monitoring and progression of missing-person investigations View source Failure to discuss and confirm AWOL risk grading with police call-takers View source Failure to require early provision of current risk assessments and completed AWOL forms View source Failure to trigger specialist-officer interventions for vulnerable or high risk missing persons View source Insufficient appropriately trained staffing to secure the return of absconding PICU patients View source Reliance solely on police assistance to secure the return of absconding PICU patients View source Failure to consider the full range of powers to secure the return of absconding PICU patients View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Stephen TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Mismatch between AWOL and missing-person risk assessment grading criteria
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing .
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of patient transport for absconding-patient returns
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances .
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and progression of missing-person investigations
Wider context from the report “3. Sussex Police’s use of their Missing Persons Policy
I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details.
In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team.
I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention .
I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss and confirm AWOL risk grading with police call-takers
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing.
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to require early provision of current risk assessments and completed AWOL forms
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing.
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger specialist-officer interventions for vulnerable or high risk missing persons
Wider context from the report “3. Sussex Police’s use of their Missing Persons Policy
I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details.
In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team.
I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention.
I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient appropriately trained staffing to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members . This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Reliance solely on police assistance to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the full range of powers to secure the return of absconding PICU patients
Wider context from the report “1. s.18 Mental Health Act 1983 powers & Mill View Hospital.
During the inquest Mill View Hospital accepted that it was their responsibility to secure the return of a patient who was detained under s.3 of the Mental Health Act 193 and who had absconded. However I heard that they were often not able to do so without the support of the police.
The evidence I heard was that the Psychiatric Intensive Care Unit (PICU), known as the Pavilion Ward, rarely had sufficient staff resources to allow them to send the required minimum of 2 staff members to try and negotiate a return of an absconding patient.
I also heard that, if the Hospital considered that the patient would be unwilling to return, it would require them to send at least 5 appropriately trained staff members. This would mean that the staffing of other wards would be impacted and also that the Prevention and Management of Violence and Aggression (PMVA) trained team might not be available for any other incidents. In addition the evidence was that the Hospital had no means of transporting a patient in these circumstances.
The Pavilion Ward Matron informed me that the ward relied on assistance from the police in relation to all patients who absconded from the PICU. The matron was not aware of any circumstances where Mill View Hospital had utilised its powers under s.18(1) of the Mental Health Act 1983 to authorise in writing ‘any other person’ to exercise their powers to seek the return of an absconding patient.
I am concerned that Mill View Hospital rely solely upon the police to assist them when the police have their own resourcing issues. I am further concerned that the Hospital has not considered the full range of their powers to secure the return of PICU patients who might pose a significant risk of harm, or death, to themselves and/or others after absconding.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate medium-risk missing-person reports without an assigned officer within two hours to G99 and, if necessary, the Critical Incident Manager.
Verbatim wording from the response “3.1 – Escalation if resources prevent allocation within 2 hours” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have the Duty Inspector support sergeants by dip-checking threat assessments and the quality and sufficiency of lines of enquiry for medium-risk cases from mental health facilities.
Verbatim wording from the response “Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level.
The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.
Verbatim wording from the response “Developing a Missing Persons Template (including an action plan)” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Missing Person Team’s terms of reference to identify enhancements to its support during the initial response phase.
Verbatim wording from the response “3.4 Missing Person Team Terms of Reference to be reviewed
The terms of reference to which the missing person team works is to be reviewed by the Force ‘Missing Persons Working Group’.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.
Verbatim wording from the response “Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Sergeants’ existing missing-person training to include obtaining and assessing information and intelligence.
Verbatim wording from the response “3.5 Training provided to Sergeants
The existing training that is currently provided to Sergeants who oversee missing person investigations will be reviewed by our Learning & Professional Development Team, who are responsible for preparing and delivering training.
Current training includes the function of command, assessing threat, risk & harm, setting and monitoring of proportionate lines of enquiry and handover processes.
We intend to include now additionally obtaining and assessing information & intelligence (as referred to in 3.3 above).
Where the training can be enhanced, additional formal training and/or Continued Professional Development will be introduced.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify the investigation officer when a missing person’s location is identified and escalate cases without an assigned officer to G99 or the Critical Incident Manager.
Verbatim wording from the response “When information is received relating to the location of a missing person and attendance by an officer is necessary, an officer will be assigned to that location in line with the threat, harm and risk presented.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sussex Partnership Foundation Trust is responsible for addressing S18 powers and Mill View Hospital matters.
Verbatim wording from the response “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Missing Person Team cannot take all investigations from first report because it is small and lacks 24/7 cover.
Verbatim wording from the response “The team has specialist expertise and effective working relationships with many of our partners, providing real benefit to investigations. However, as a small team, cover is not 24/7 so it would not be possible for the team to take on all investigations from first report. The review will consider what, if any, enhancements can be made to assist their colleagues. We anticipate this review will be completed and presented to our Vulnerability Board in April 2022 and any changes that result will take effect immediately.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Command responsibility for medium-risk missing persons will remain with sergeants because transferring it could reduce oversight through increased inspector demand.
Verbatim wording from the response “Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level.
The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation S18 Mental Health Act powers and Mill View Hospital matters fall outside the respondent’s remit.
Verbatim wording from the response “This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
4 Jun 2021 David Conway ORMESHER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Failure to retain the personal radio appropriately during police vehicle operations View source Failure to deploy the siren when required View source Failure to keep the in-car radio switched on View source Inadequate driver training on appropriate driving and journey planning View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Create an NCALT package supporting mandated vehicle-radio teaching for new starters.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 June 2021. View source
Action
Include mandated vehicle-radio-use and procedure teaching in all new-starter foundation training.
Stated completedThe respondent said that this action was complete when they made their response on 4 June 2021. View source
Action
Operate a Driver Behaviour Working Group reviewing telematics, training, vehicle incidents, pursuit learning, and health and safety trends.
Stated completedThe respondent said that this action was complete when they made their response on 4 June 2021. View source
Action
Issue force-wide messaging reinforcing appropriate driving, justification of actions, journey planning, and passengers’ duty to report dangerous driving.
Stated plannedThe respondent said that this action was planned when they made their response on 4 June 2021. View source
Action
Operate a Police Vehicle Incidents meeting overseeing policy, incident reviews, lessons learned, driver behaviour, and related sanctions or learning outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 4 June 2021. View source
Action
Complete rollout of a mandated bespoke vehicle-radio training package for driving-permit holders, covering radio operation, policy, and passenger responsibilities.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 June 2021. View source See 3 more actions
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AI-generated summary
David Conway ORMESHER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Conway ORMESHER's death was investigated from 5 September 2017, with the investigation concluding at the end of an inquest on 17 May 2021. Concerns identified included the use of the in-car radio and siren, handling of the personal radio, excessive speed, and the need to reinforce driver-training requirements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to retain the personal radio appropriately during police vehicle operations
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy the siren when required
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the in-car radio switched on
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate driver training on appropriate driving and journey planning
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create an NCALT package supporting mandated vehicle-radio teaching for new starters.
Verbatim wording from the response “I have also instructed our Learning & Professional Development team to include a mandated input on vehicle radio use and procedure to all new starters as part of their foundation training with Sussex Police. This is now included in the mandated teaching in all Dedicated Coaching Units, which will be supported by an NCALT package that is in the process of being created.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include mandated vehicle-radio-use and procedure teaching in all new-starter foundation training.
Verbatim wording from the response “I have also instructed our Learning & Professional Development team to include a mandated input on vehicle radio use and procedure to all new starters as part of their foundation training with Sussex Police. This is now included in the mandated teaching in all Dedicated Coaching Units, which will be supported by an NCALT package that is in the process of being created.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Driver Behaviour Working Group reviewing telematics, training, vehicle incidents, pursuit learning, and health and safety trends.
Verbatim wording from the response “I have also instructed ████████ to reinforce to all police drivers, the need to drive appropriately, justify their actions and plan their journey using all available information. As well as highlight that under the code of ethics, it is passengers’ duty to report any dangerous driving they witness that may put themselves or the public at risk. This will take the form of force wide messaging to all relevant officers in the force. Sussex Police has invested in Telematics, a vehicle management system which provides information about vehicles so the force can monitor how vehicles are being driven and track vehicle movements. A Driver Behaviour Working Group is also in place which reviews trends shown by Telematics, driver training, police vehicle incidents, pursuit learning and health and safety.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue force-wide messaging reinforcing appropriate driving, justification of actions, journey planning, and passengers’ duty to report dangerous driving.
Verbatim wording from the response “I have also instructed ████████ to reinforce to all police drivers, the need to drive appropriately, justify their actions and plan their journey using all available information. As well as highlight that under the code of ethics, it is passengers’ duty to report any dangerous driving they witness that may put themselves or the public at risk. This will take the form of force wide messaging to all relevant officers in the force. Sussex Police has invested in Telematics, a vehicle management system which provides information about vehicles so the force can monitor how vehicles are being driven and track vehicle movements. A Driver Behaviour Working Group is also in place which reviews trends shown by Telematics, driver training, police vehicle incidents, pursuit learning and health and safety.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Police Vehicle Incidents meeting overseeing policy, incident reviews, lessons learned, driver behaviour, and related sanctions or learning outcomes.
Verbatim wording from the response “A Police Vehicle Incidents meeting oversees new policy, reviews vehicle incidents and share lessons learnt. The panel also reviews behaviour of drivers and promote this through a full range of sanctions or learning outcomes. A point system has been introduced with the aim of making interventions at lower levels and avoiding more serious incidences occurring in future.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete rollout of a mandated bespoke vehicle-radio training package for driving-permit holders, covering radio operation, policy, and passenger responsibilities.
Verbatim wording from the response “I have instructed ████████ in conjunction with our Learning & Professional Development team to design a bespoke training package relating to the use of the vehicle radio. This will be mandated to all members of Sussex Police officers and staff who hold a driving permit to complete. It will include the operation of the radio, a reminder of the Sussex Police policy and roles and responsibilities of any passenger within the vehicle. This is already in the later stages of development and rollout should be completed by the end of October 2021.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies are considered unable to cover the rare eventuality of a passenger failing to return another officer’s personal radio.
Verbatim wording from the response “Recommendation 3 – The personal radio should not be handed to the passenger in the police vehicle and not returned immediately.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The driving failings are not considered systemic in Sussex Police or caused by its driver training.
Verbatim wording from the response “This was tragic case that was found to be caused by a combination of factors, including the driving of ████████. I do not believe that these failings are systemic in Sussex Police and nor are they as a result of our driver training.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing response-driver training is considered commensurate with College of Policing and NPCC standards, so fundamental training changes are not required.
Verbatim wording from the response “Having reviewed the training that is delivered to response drivers by Sussex Police I am satisfied that we are delivering training that is commensurate with direction given by the College of Policing and the NPCC Driver Training lead.” Source location Response from Sussex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Airwave policy sufficiently requires vehicle and personal radios to remain switched on and operational at all times.
Verbatim wording from the response “The in-car radio (as with the personal hand-held radio issued to officers) is part of the ‘Airwave’ mobile communications network which is used throughout the UK by all emergency services. Having reviewed our policies and procedures governing their use I am satisfied that Sussex Police policy 594/2021 gives a sufficiently robust direction to all Airwave users to ensure that both their personal handsets and vehicle sets are switched on and operational at all times;” Source location Response from Sussex Police
Open published response
28 May 2021 KEVIN JOHN FITTON · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 12 Poor or inadequate implementation of Care Act assessments View source Failure to seek specialist Acquired Brain Injury support View source Failure to respond to deterioration in living conditions, physical health and drug use View source Failure to repeat Care Act assessments annually View source Lack of training on the Mental Capacity Act and Care Act Codes of Practice View source Lack of lead and coordination View source Failure to use best interests policy appropriately View source Failure to understand how Acquired Brain Injury affects abilities View source Failure to understand the interaction between Acquired Brain Injury and substance use View source Poor communication between teams and individuals View source Inadequate staff training in Acquired Brain Injury View source Lack of capacity assessments View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
KEVIN JOHN FITTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Poor or inadequate implementation of Care Act assessments
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented . It should have been repeated annually – it was not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist Acquired Brain Injury support
Wider context from the report “(2) There was a failure to seek specialist support regarding Acquired Brain Injury (ABI) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to deterioration in living conditions, physical health and drug use
Wider context from the report “(7) There was a failure to react to the deterioration in Mr Fitton’s living conditions, his being cuckooed, the downward slide in his physical health and the increase in his drug use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat Care Act assessments annually
Wider context from the report “(9) There was a reasonable Care Act Assessment in 2017 however it was poorly/inadequately implemented. It should have been repeated annually – it was not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of training on the Mental Capacity Act and Care Act Codes of Practice
Wider context from the report “(8) Staff received no adequate training in dealing with ABI. There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of lead and coordination
Wider context from the report “(6) Lead and Co-ordination were lacking.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use best interests policy appropriately
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to understand how Acquired Brain Injury affects abilities
Wider context from the report “(3) There was a failure to understand the way Mr Fitton’s ABI impacted on his abilities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the interaction between Acquired Brain Injury and substance use
Wider context from the report “(4) There was a failure to understand how ABI impacted on Mr Fitton’s substance use and vice versa .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Poor communication between teams and individuals
Wider context from the report “(5) Communication between the various teams and individuals were poor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in Acquired Brain Injury
Wider context from the report “(8) Staff received no adequate training in dealing with ABI . There was no training on the Codes of Practice for the Mental Capacity Act or the Care Act.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity assessments
Wider context from the report “(1) There was an almost complete reliance of assumption of capacity. The lack of capacity assessments resulted in failure to identify the area and support needed by Mr Fitton and a failure to use best interests policy appropriately.
” Open source report
25 Feb 2020 Mr. Thomas REILLY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Failure to route safeguarding alerts to the appropriate generic mental health service mailbox View source Delays in processing medium-risk safeguarding alerts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr. Thomas REILLY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Thomas REILLY visited Beachy Head on 1 October 2019 intending to jump, but changed his mind after receiving support. A safeguarding alert was delayed and then sent to an individual mailbox rather than the appropriate generic mailbox; it was actioned after Mr Reilly had been found dead early on 3 October. The report identified a missed opportunity to prevent his suicide and stated that the safeguarding system was fundamentally flawed and needed urgent review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to route safeguarding alerts to the appropriate generic mental health service mailbox
Wider context from the report “When the police officer arrived back at Eastbourne police station he raised a safeguarding alert.
This alert was sent to the Multi-Agency Safeguarding Hub (MASH).
When received there it should have triggered fast onward transmission to the appropriate agency to support Mr Reilly.
It was received at MASH at 15.33hrs on the 1st October but, although it had been sent as soon as possible after the incident, it was clear from the evidence that it stood no chance of being dealt with on the 1st.
(2) The alerts are graded low, medium and high risk.
The high risk alerts stand a chance of being dealt with timeously. This was graded medium which was a reasonable assessment.
Everything else will be delayed. Indeed the alert for Mr Reilly was not dealt with until 12:40 hours on Friday, the 4th of October.
That is after lunch on a Friday.
(3) This alert was not dealt with again until Monday, the 7th of October when it was sent to the mailbox of a named mental health social worker ████████ rather than to the Sussex Partnership Foundation Trust generic mailbox where it would have been actioned on the 7th.
As it was, it was received by ████████ on the morning of the 8th.
She actioned it at once.
Too late, Mr Reilly had been found dead early on the 3rd of October.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Delays in processing medium-risk safeguarding alerts
Wider context from the report “When the police officer arrived back at Eastbourne police station he raised a safeguarding alert.
This alert was sent to the Multi-Agency Safeguarding Hub (MASH).
When received there it should have triggered fast onward transmission to the appropriate agency to support Mr Reilly.
It was received at MASH at 15.33hrs on the 1st October but, although it had been sent as soon as possible after the incident, it was clear from the evidence that it stood no chance of being dealt with on the 1st.
(2) The alerts are graded low, medium and high risk.
The high risk alerts stand a chance of being dealt with timeously. This was graded medium which was a reasonable assessment.
Everything else will be delayed. Indeed the alert for Mr Reilly was not dealt with until 12:40 hours on Friday, the 4th of October.
That is after lunch on a Friday.
(3) This alert was not dealt with again until Monday, the 7th of October when it was sent to the mailbox of a named mental health social worker ████████ rather than to the Sussex Partnership Foundation Trust generic mailbox where it would have been actioned on the 7th.
As it was, it was received by ████████ on the morning of the 8th.
She actioned it at once.
Too late, Mr Reilly had been found dead early on the 3rd of October.
” Open source report
7 Feb 2020 Mark Oliver George Mallinson · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Failure to provide suicide intervention training to all frontline police staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Oliver George Mallinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Oliver George Mallinson made numerous threats to take his own life over several hours after police sought to arrest him, and he died by suicide between 03.20am and 04.24am on 3 December 2018. The principal concern was that suicide-intervention training designed to save lives was not being provided to all frontline police staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide intervention training to all frontline police staff
Wider context from the report “████████ provided a statement about the training given to police officers in the area of suicide intervention. ████████ stated that he had created a training package for new recruits. This training is designed to give first responders pointers to save lives and to buy time.
I received further information during the course of the inquest that most new recruits of Sussex Police in the last 12-18 months had received the training. However this training is not being rolled out to the remainder of the police force. The concern I have is that training specifically designed to save lives is not being provided to all front line staff.
” Open source report
12 Apr 2019 Duncan Tomlin · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Insufficient training on atypical seizure and post-seizure behaviour View source Insufficient sharing and requesting of information needed to assess restraint safety View source Lack of guidance defining monitoring requirements for restrained detainees View source Reliance on breathing sounds as insufficient monitoring of prone restrained detainees View source Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present View source Inconsistent understanding of when to commence CPR for abnormal or distressed breathing View source Failure to prioritise assessment of detainees after control is obtained over speedy removal from the scene View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Duncan Tomlin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on atypical seizure and post-seizure behaviour
Wider context from the report “Understanding aspects of Epilepsy and Seizures
5. The training material which has been provided to me on behalf of Sussex Police covers many aspects of epilepsy and seizure that were explored during the inquest. The training material indicates that if it is available to the trainer, participants will be shown a video which informs the viewer of the way in which a person may present post seizure, namely confused, vulnerable, perceiving aggression from others and at risk of lashing out due to misunderstanding. I have also been provided with a copy of a training manual provided by Epilepsy Action which was sent to ACPO in 2011. Aspects of the evidence from the family in this inquest were entirely consistent with the less common presentations of a person in an atypical or post seizure state.
Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances, the reactions of a person suffering an atypical seizure or in a post seizure state, could be misconstrued as violence and resistance were officers not to appreciate that fact that their presentation may be part of a medical condition and restraint in such circumstances could have inherent and fatal risks. It is therefore of importance that training extends beyond the two more well known types of seizure and that post seizure behaviour is also understood in general terms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient sharing and requesting of information needed to assess restraint safety
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset . These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene, rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting. Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining monitoring requirements for restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers . A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient, particularly when they can be hard to hear, mishear or misinterpreted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Reliance on breathing sounds as insufficient monitoring of prone restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers. A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient , particularly when they can be hard to hear, mishear or misinterpreted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present
Wider context from the report “Importance of heightened risk of prone restraint when multiple factors affecting breathing are present
1. The current and earlier training plans, manuals and policies examined as part of the evidence in this inquest make clear references to risks associated with: (a) positional asphyxia; (b) handcuffs and limb restraints; (c) incapacitant spray; (d) acute behavioural disorder or symptoms thereof; (e) lack of oxygen due to physical exertion; (f) drug/alcohol intoxication; and (g) seizures.
Although there is some cross-referencing between the various risk factors, the heightened risk to a person in prone restraint when a number of these factors are present is not emphasised or sufficiently emphasised . The multifactorial matters that can impact on a person’s ability to breathe and the heightened risks to a person in a position of prone restraint when experiencing such multiple factors are critical to the assessment of risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of when to commence CPR for abnormal or distressed breathing
Wider context from the report “Commencing CPR
4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing.
The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped . Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise assessment of detainees after control is obtained over speedy removal from the scene
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset. These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene , rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting . Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include an epilepsy video in initial officer training and refresh it during refresher training every three years.
Verbatim wording from the response “In relation to epilepsy in particular, there is a video which is included in the initial officer training course and is refreshed every 3 years in the refresher training. Sussex Police are considering hosting a link to that video on their internal website for all officers to be able to view.” Source location 2019-0135-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train and assess learners monitoring an unconscious casualty lying face down, including differences in visible chest movement.
Verbatim wording from the response “For the last two years Sussex Police has trained and assessed each learner monitoring an unconscious casualty who has fallen face first (another learner is the casualty during this exercise) and point out the appearance of rise and fall looks different than those on their backs – which links to those being placed in a prone position. We also use state of the art computerised cardiopulmonary resuscitation (CPR) manikins to assess each learner individually. This gives live accurate feedback on the effectiveness of CPR technique with percentile scoring of both breathing and compressions. This is a pass/fail assessment.” Source location 2019-0135-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Teach breathing monitoring through sound, touch, and observation of rib-cage movement, with annual refresher coverage.
Verbatim wording from the response “Monitoring is covered across a number of Lessons such as ABD, Epilepsy, conscious and unconscious casualty and Positional Asphyxia. The information given on monitoring breathing in training includes more than noisy breathing – it also includes feel, touch and rise and fall of the rib cage. This is included in the lesson plans and is refreshed each year.” Source location 2019-0135-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Basic first-aid training provides officers with knowledge and skills suitable for their policing role.
Verbatim wording from the response “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time” Source location 2019-0135-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.
Verbatim wording from the response “We are currently delivering nationally agreed training packages and any alteration to these should be agreed nationally with approval of all parties. The benefit in delivering training packages (for all mandatory training, not just Personal Safety Training) is they are consistent across the UK, all police officers are trained in the most current, relevant and up to date thinking which is designed using the latest research and learning from all Forces. We are aware this is currently being reviewed by NPCC and any alterations passed onto Forces in order for them to include in their training. It would be expected these alterations would be completed by the end of 2020.” Source location 2019-0135-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.
Verbatim wording from the response “Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time” Source location 2019-0135-Response-by-Sussex-Police
Open published response
10 Apr 2019 David DOOLEY · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Lack of police awareness of life-line locations and use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David DOOLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David DOOLEY died in an incident in the sea at Brighton seafront. The report identified that police officers did not know the location of nearby life lines, causing a delay in attempts to throw one, although it considered that adverse weather and sea conditions would have prevented an earlier successful rescue attempt. It also raised concerns about public awareness of the dangers of entering the sea after consuming alcohol or taking drugs, and the inquest concluded that the death was accidental.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police awareness of life-line locations and use
Wider context from the report “(1) The exact location of the life lines on Brighton seafront were not known to the Police officers who attended the scene of the incident. Mr Dooley’s friend informed security at the local night club that he believed that Mr Dooley was in the sea and the police officers attended very quickly. The location of the life lines were not known to the police officers who attended the beach. A life line had to be brought from the Police Station. As a consequence, there was a delay in a life line being thrown to Mr Dooley. There was in fact a life line 30 metres from where Mr Dooley’s friend had first alerted the night club security that Mr Dooley was in the sea. Although there was a delay in attempts being made to throw Mr Dooley a life line, taking into consideration the adverse weather conditions (Storm Callum) and sea conditions, even if a line had been thrown earlier, I consider it would not have been able to be thrown to Mr Dooley successfully.
(2) Steps should be taken to increase the police awareness of the location of life lines and their use, so that they can be used more expeditiously.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add coastal throw-ring locations to the Sussex Police digital mapping system.
Verbatim wording from the response “As previously explained, there are 25 throw rings situated along the seafront of Brighton & Hove, the location of which have been mapped and recorded on prompt cards for Police officers and staff. The intention is to share this with the Brighton & Hove Crime Reduction Partnership which will include night time economy workers such as door staff. Although prompt cards have been provided to officers and staff showing the location of coastal throw rings, the longer term aim is to have these locations also available on our Sussex Police digital mapping system. There are some technical challenges but CI Bennett is engaged at the appropriate level and aims to finalise this by 1st September 2019.” Source location 2019-0127-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce throw lines as standard equipment in marked Sussex Police Response and other marked police vehicles.
Verbatim wording from the response “4. Following on from previous action taken by Sussex Police in relation to water safety awareness and additional training for police officers and staff, ‘throw lines’ were purchased and made part of the standard equipment for all Sussex Police marked Response vehicles in August 2018. In November 2018 throw lines were also introduced as standard equipment on all marked police vehicles in Sussex. In early 2019 this was further enhanced with the introduction of the joint Surrey and Sussex force policy on ‘Water Safety for first responders’ (1184/2019). This policy document also includes a comprehensive toolkit for officers and staff, and also a guidance sheet on the effective use of the throw lines now available in all marked police vehicles.” Source location 2019-0127-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute prompt cards showing Brighton and Hove coastal throw-ring locations to all divisional police officers and staff.
Verbatim wording from the response “2. Following this tragic incident the location of publically available throw lines and rings is more widely known among officers and staff. Acting on the recommendations of the Coroner’s report, prompt cards showing the location of the 25 throw rings currently provided by Brighton & Hove City Council have been obtained and have been sent to all Police officers and staff on Brighton & Hove Division.” Source location 2019-0127-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the joint Surrey and Sussex policy, toolkit and guidance on water safety and throw-line use for first responders.
Verbatim wording from the response “4. Following on from previous action taken by Sussex Police in relation to water safety awareness and additional training for police officers and staff, ‘throw lines’ were purchased and made part of the standard equipment for all Sussex Police marked Response vehicles in August 2018. In November 2018 throw lines were also introduced as standard equipment on all marked police vehicles in Sussex. In early 2019 this was further enhanced with the introduction of the joint Surrey and Sussex force policy on ‘Water Safety for first responders’ (1184/2019). This policy document also includes a comprehensive toolkit for officers and staff, and also a guidance sheet on the effective use of the throw lines now available in all marked police vehicles.” Source location 2019-0127-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require police CCTV operators to scan for water-safety equipment and highlight its location during initial responses to people believed in danger in water.
Verbatim wording from the response “Changes to our standard operating procedures within the Sussex Police Contact Centre will with immediate effect include police CCTV operators being tasked via police incident management system (“Webstorm”) to ‘scan’ for water safety equipment at the location of an incident, as part of the initial response where it is believed someone has entered the sea and is thought to be in danger. The wording that has been introduced as an automated prompt is ‘In incidents where a person has entered the water, on shore or inland, where there is a CCTV view, the identification of life saving equipment, such as throw lines, should be highlighted to attending officers/staff and members of the public who may have called on 999.’” Source location 2019-0127-Response-by-Sussex-Police
Open published response
18 Jan 2018 Paul Lawrence Hanton · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Failure to make appropriate referrals to other police forces View source Lack of consolidated information for AWOL emergency calls View source Failure to clearly record the initial risk assessment in the CAD View source Unequal police response to high-risk informal and sectioned patients View source Unclear AWOL policy on waiting for clinical staff discussion View source Delays in undertaking timely local police actions View source Unavailability of hospital CCTV for police viewing View source Lack of joint policy with the Adult Safeguarding Board View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Lawrence Hanton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate referrals to other police forces
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of consolidated information for AWOL emergency calls
Wider context from the report “1) Need for clear information to be given by hospital staff when making the 999 call to report a patient has gone AWOL in order to proactively answer the known risk questions and maximise the opportunity for police to take timely action to trace the patient within the golden hour.
I heard from ████████ Service Director, that when a 999 call is made relevant information would need to be drawn from several sources including the patient’s form (personal/physical details & photo), any signing in/out form (last known clothing) and latest risk assessments/plan with details of recent incidents that inform the risk assessment. Inevitably, when a patient goes missing the AWOL policy needs to be followed including internal and external searches; notification of relevant senior staff etc. At times of pressure such as these it would be advisable to have all the relevant information in one location for ease of access by the designated person who makes the call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record the initial risk assessment in the CAD
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unequal police response to high-risk informal and sectioned patients
Wider context from the report “6) Police to consider equal response to informal as well as sectioned patients if guided by clinical staff of high risk. I heard from senior staff at Langley Green that there is a discernibly different response from police when the missing person is an informal patient rather than under a MHA order . In the latter case, often a blue light police car is immediately dispatched to the hospital and a room/locality search takes place. This is not the case with an informal patient yet the same high risk of self-harm or suicide or risk of causing injuries to others may exist . In other words, there seems to be a general perception that informal patients are less unwell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unclear AWOL policy on waiting for clinical staff discussion
Wider context from the report “3) Langley Green to consider review and amendment of current AWOL policy. This may be necessary given ████████ indication that he does not believe staff need to wait to have a discussion with clinical staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking timely local police actions
Wider context from the report “4) Police to ensure the initial risk assessment is clearly endorsed in the CAD and timely actions are undertaken both locally and appropriate referrals are made to other Forces.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of hospital CCTV for police viewing
Wider context from the report “2) Langley Green to ensure that hospital CCTV is accessible at all times for police viewing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of joint policy with the Adult Safeguarding Board
Wider context from the report “5) Police to consider joint policy with Adult Safeguarding Board .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver scenario-based training to contact handlers and controllers on recording missing-person incidents under the new process.
Verbatim wording from the response “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the jointly agreed absent-without-leave and informal-missing-patients policy through partner-agency consultation, including seeking Safeguarding Board comments and considering coroner recommendations.
Verbatim wording from the response “Point five identifies the need to consider a joint policy with the Adult Safeguarding Board. Sussex Police and Sussex Partnership NHS Foundation have a jointly agreed policy relating to patients absent without leave / informal missing patients which applies to all patients including those detained under the Mental Health Act 1983, subject to Guardianship, Supervised Community Treatment Orders as well as those in hospital informally. The document provides guidance for managers and staff regarding duties, responsibilities and actions to be taken when a patient is absent without leave or provides the legal framework which sets out these duties and responsibilities. This Policy (a copy of which is attached) was due for review in November 2017 and is currently in the process of consultation with all partner agencies prior to the finalisation of any amendments and additions.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide duty inspectors with continuing professional development on managing threat, harm and risk and documenting decisions clearly in incident logs.
Verbatim wording from the response “This included scenario based exercises and was delivered over a 12 week training cycle between January and March 2017 prior to the new process being invoked in May. It was further audited in June before the policy went live in September 2017. All inspectors who perform the role of the Duty Inspector were also required to attend a Continued Professional Development two day course between March and May 2017 around the management of threat, harm and risk and the need to document decisions clearly within CADs.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and apply new missing-person call-handling guidance requiring clear recording of risk levels in incident logs.
Verbatim wording from the response “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Patient status does not determine response level; response is determined by assessed risk, regardless of whether the patient is informal or sectioned.
Verbatim wording from the response “Point six asks the police to consider whether there is an equal response to informal as well as sectioned patients if they are assessed by clinical staff as high risk. I can assure you that whether they were an informal or sectioned patient would be noted but would not determine the level of response. This is determined by the level of risk which is a combination of the likelihood of harm coming to the missing person or the wider public, and the potential seriousness of harm that might result.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sussex Partnership NHS Foundation Trust will respond directly to concerns one, two and three.
Verbatim wording from the response “Points one, two and three (as numbered in the report) will be responded to by Sussex Partnership NHS Foundation Trust directly to you.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing missing-person processes, policies, risk controls and staff training are considered sufficient to address the concerns.
Verbatim wording from the response “With regard to point four, new call handling guidance within the force missing person policy was published in September 2017 and outlines how the risk level must be recorded clearly within the CAD (incident log). A copy of this is attached titled ‘Missing person policy, Appendix B: call handling guidance’. This followed a review of Sussex Police's response to Missing Persons. The detailed design process subjected of consultation with all inspectors across the force. This established how risk decisions are made and applied in a consistent manner by all inspectors, and a training package was subsequently designed for all contact handlers and controllers taking them through the process of recording Missing Person incidents from the point of call.” Source location 2018-0021-Response-by-Sussex-Police
Open published response
24 Jul 2017 GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Visitors’ language difficulties and lack of experience with the sea View source Failure to maintain effective public communication about coastal safety View source Lack of formal governance and control of coastal risk management View source Insufficient education and awareness of coastal dangers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Visitors’ language difficulties and lack of experience with the sea
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea . The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective public communication about coastal safety
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process ,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal governance and control of coastal risk management
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements . Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime , given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient education and awareness of coastal dangers
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea .
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report
17 Mar 2015 Alasdair Neal Penny · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Failure of bridge railings to prevent easy mounting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alasdair Neal Penny · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alasdair Neal Penny, a 23-year-old man, jumped from a road bridge onto the road below on 4 May 2014 and died from multiple injuries. The bridge had previously been the site of a suicide, and the concern was whether additional protection could make it more difficult to use the bridge as a suicide site and minimise recurrence.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sussex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of bridge railings to prevent easy mounting
Wider context from the report “This Bridge has been the site of 2 suicides in 2011 and 2014; I am unaware if there have been any other successful suicides at this location before then, but if so, not in the very recent past.
In each of the 2 cases the deceased jumped from the bridge on to the road below, a distance of 10-11 metres. The 2 footpaths that bound the carriageway each have a metal railing and the height of the railing is such that they can be quite easily mounted.
There is a series of discrete notices on the mesh infill to the railings, giving details, I understand, of the Samaritans.
I cannot, and do not, offer a solution I certainly recognise that merely raising the level of the railing may not prevent the determined person to climb up and jump. But it might well stop the spontaneous jumper.
I understand that I do not know whether it is possible/feasible to provide extra/or some other form of protection in order to make it more difficult for the bridge to be used as a suicide site.
However, I do believe that the whole situation should be reconsidered in case something can be reasonably implemented to minimise the possibility of a recurrence.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations