Mr. Thomas REILLY · Prevention of Future Deaths report

On 9th October 2019 I commenced an investigation into the death of Mr. Thomas REILLY. The investigation concluded at the end of the Inquest on 13th February 2020. The conclusion of the inquest was that “HE TOOK HIS OWN LIFE”

See Record of Inquest

(1) Mr Reilly visited Beachy head on the 1st of October 2019. His intention was to jump off but, when approached by the Chaplains, he changed his mind. Police were called and after discussion and support they saw Mr Reilly safely on his way back to Hove following his car for a while.
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.

(4) If the alert had been actioned late on the 1st or early on the 2nd of October (as I believe it should have been), it would have produced an immediate reaction from ████████ who would have got in touch with Mr Reilly and arguably her engagement with him may have prevented his suicide.

It was clear from the evidence I heard that the system is fundamentally flawed and needs urgent review.

In my summing up I found that at the very least there was a missed opportunity to prevent Mr Reilly’s suicide and indeed given that this relationship with ████████ was good and strong it may well have been the only opportunity to prevent it.