Miles Hurley
9 Jul 2024 · Coroner Karen Henderson · West Sussex, Brighton & Hove
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of effective communication between police officers
“Lack of effective Communication between police officers”
2. lack of relevant documentation by police
“Lack of relevant Documentation by the Police”
3. lack of effective documentation and communication between LDS and police
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite”
4. inadequate Memorandum of Understanding
“Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement”
This report
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
Closely relatedConfidence 0.90 · high
Earlier report
“(4) There was a failure to understand how ABI impacted on Mr [name redacted] substance use and vice versa. (5) Communication between the various teams and individuals were poor. (6) Lead and Co-ordination were lacking.”
This report
“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 [the deceased] who was not known to the police.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model.”
This report
“Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.”
Responses
2024-0364-Response-from-Midlands-Partnership-NHS-Trust.pdf ↗· Midlands Partnership University NHS Foundation Trust
2024-0364-Response-from-NHS-England.pdf ↗· NHS England
2024-0364-Response-from-NPCC.pdf ↗· Midlands Partnership University NHS Foundation Trust
Stated action
“The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.”
Stated action
“It is recognised that there is a lack of information being recorded on custody detention logs. The College of Policing Hydra packages are in place to improve this and the NPCC are supportive of this training for custody staff. I understand that Sussex Police have now adopted this training.”
Stated action
“Guidelines around supporting a LDS Practitioner as to when it is appropriate to undertake a formal mental health assessment when an individual is intoxicated is a matter for the LDS provider.”
Stated action
“National guidelines are in place in the form of PACE Code C in relation to identifying vulnerability in police custody and the provision of an Appropriate Adult. It is not clear from the information in the report as to why the interviewing officer did not deem the support of an Appropriate Adult for Mr [name redacted] necessary in this case.”
2024-0364-Response-from-Sussex-Police.pdf ↗· Sussex Police