PFD report

Harry Benjamin SOUTHERN · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 23 Jan 2025•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to provide young people and their families with information about available suicide prevention services
    Part of recurring concern: Failure to provide accessible suicide-prevention service information to people at riskPart of recurring concern: Failure to provide families with information needed to support people receiving mental health care
  2. Reduction of services for people with mental health difficulties due to cutbacks and funding issues
    Part of recurring concern: Insufficient mental health service capacity for timely patient care
  3. Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities
    Part of recurring concern: Failure to provide accessible suicide-prevention service information to people at riskPart of recurring concern: Inconsistent implementation of suicide-prevention systems
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Promote online mental-health signposting information through NHS, primary-care, local-authority and voluntary-sector partners.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2025.
  2. Action

    Raise the gap between helpline demand and available financial resources with NHS Sussex commissioners.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2025.
  3. Action

    Improve Sussex Mental Health Line productivity to address demand and unanswered calls.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.

    Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide young people and their families with information about available suicide prevention services

Wider context from the report

“During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

Is this part of a recurring concern?

Yes — Failure to provide accessible suicide-prevention service information to people at risk; Failure to provide families with information needed to support people receiving mental health care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Reduction of services for people with mental health difficulties due to cutbacks and funding issues

Wider context from the report

“During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

Is this part of a recurring concern?

Yes — Insufficient mental health service capacity for timely patient care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities

Wider context from the report

“During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

Is this part of a recurring concern?

Yes — Failure to provide accessible suicide-prevention service information to people at risk; Inconsistent implementation of suicide-prevention systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of suicide prevention contact numbers to provide continuous access to someone able to speak with callers

Wider context from the report

“During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak to them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this. ”

Is this part of a recurring concern?

Yes — Failure to provide accessible suicide-prevention service information to people at risk; Inconsistent implementation of suicide-prevention systems; Unreliable communication access for people requiring support.

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

Promote online mental-health signposting information through NHS, primary-care, local-authority and voluntary-sector partners.

Verbatim wording from the response

“I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Raise the gap between helpline demand and available financial resources with NHS Sussex commissioners.

Verbatim wording from the response

“By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Improve Sussex Mental Health Line productivity to address demand and unanswered calls.

Verbatim wording from the response

“By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Promote the 24/7 Text SUSSEX to 85258 mental-health support service through the Trust and partner organisations.

Verbatim wording from the response

“An additional service which is now regularly promoted by both the Trust and partner organisations, including campaigns which are targeted specifically at students, is 'Text SUSSEX to 85258'. It is a digital means for people to access help with their mental health. The service, which is delivered through the national text messaging service Shout, is free and is available 24 hours a day, seven days a week.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Make ongoing Sussex Mental Health Line improvement a key objective in the 2025/26 annual plan.

Verbatim wording from the response

“By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Change Sussex Mental Health Line working patterns to improve call accessibility.

Verbatim wording from the response

“By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Recruit staff to improve Sussex Mental Health Line capacity.

Verbatim wording from the response

“By way of assurance, many actions have already been taken and continue to be taken to improve the accessibility of helpline support in Sussex. Following completion of the SMHL review you heard about during the Inquest, immediate actions have focused on recruitment, working patterns and productivity. Additionally, the gap between demand and financial resource has been formally raised with the Trust's commissioners, NHS Sussex, and ongoing improvement of the SMHL is a key objective within the 2025/26 annual plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Transform Staying Well into an open-access out-of-hours crisis service, rebrand and promote it, and increase its availability.

Verbatim wording from the response

“Over the last 18 months, the Staying Well service, which you heard some detail about during Harry's Inquest, has also been transformed into an open access service to provide support to people who are experiencing a self-defined mental health crisis, as an alternative to attending A&E. It is an out-of-hours crisis support service which is co-delivered by voluntary, community and social enterprise (VCSE) providers and the Trust has worked with those VCSE partners to rebrand and promote Staying Well, and increase the hours it is available, resulting in a substantial increase in the number of people attending in person.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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 launch consistent online mental-health signposting information, categorised by how people may be feeling.

Verbatim wording from the response

“I absolutely recognise, as you say, that not everyone wants or is able to use, telephone contact and the Trust has been pro-actively working with system partners to develop new and consistent online mental health signposting information to make it easier for people to find help. The new online information, which categorises services based on how a person may be feeling, was launched in July 2024 and is promoted by a wide range of NHS, primary care, local authority and voluntary sector partners. Details can be found on the Trust's public website here: Getting help with your mental health :: Sussex Partnership NHS Foundation Trust”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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

Launch multi-agency Neighbourhood Mental Health teams to coordinate access to NHS and voluntary-sector support.

Verbatim wording from the response

“In relation to alternative support, I am pleased to say that the Trust has now launched the New Neighbourhood Mental Health teams that you also heard about during the Inquest. As they are multi-agency teams they enable improved access to the breadth of services, be that NHS or voluntary sector services, to provide the best and most accessible support for those experiencing mental ill-health. I know that the importance of working collaboratively was heard throughout Harry's Inquest as he was also receiving support from his GP, a private counsellor and had third sector input too. The new Neighbourhood teams support a co-ordinated approach to ensure all system agency partners are aware of exactly what is available across, what is recognised as being a complex mix of primary and secondary healthcare as well as vital voluntary sectors.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 20 January 2025

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 range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.

Verbatim wording from the response

“All the aforementioned collaborative, partner working is part of the national strategy to improve community and crisis services to deliver more mental health crisis care in the community, close to people’s homes, through new models of care and support which is key to the long-term sustainability of the NHS. The aim being to improve accessibility of mental health support, not by focusing on improving helplines etc, but by having a range of accessible options which, collectively provide access to local support 24 hours a day, 7 days a week.”

Source location

Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 20 January 2025

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026