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recurance

Ryan Ouslem

24 Sept 2024 · Coroner Robert Simpson · West Sussex, Brighton and Hove

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. lack of awareness of suicide and mental health information on Crew Mate App

    “She was not aware of the suicide and mental health information available on the Crew Mate App which all officers had access to.”
  2. 2. inadequate mental health training provision and understanding

    “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.”
  3. 3. breakdown in joint working and information sharing between police and mental health services

    “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.”
  4. 4. insufficient structured information exchange between agencies

    “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.”

Linked reports

Repeats an earlier warningMark Mallinson7 Feb 2020 · 4 years 8 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier 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.”
Original on judiciary.uk ↗

This report

“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.”
Full chain: Lack of suicide intervention training for front line police staff
Repeats an earlier warningKevin Fitton28 May 2021 · 3 years 4 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“(5) Communication between the various teams and individuals were poor.”
Original on judiciary.uk ↗

This report

“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.”
Full chain: Inadequate communication between agencies

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error