Ryan Ouslem

Dear HMAC Robert Simpson, Inquest touching on the death of Ryan Louis Ouslem I write in response to concerns you raised following the conclusion of the Inquest into the death of Ryan Louis Ouslem, which concluded on 5th September 2024. We are grateful for the opportunity to address these concerns and trust the following information will assist. Rapid Assessment Service You have requested information from Sussex Police and SPFT regarding plans for roll out of the SPFT “Rapid Assessment Service” where practitioners from the Trust will be attending police calls which have a mental health element (where requested). In line with this, you would also like to know how information is to be shared between agencies. The roll out of the Rapid Assessment Service is being led by SPFT who are commissioned by NHS Sussex to deliver secondary mental health care in Sussex. Sussex Police are an active participant in the review process and are working collaboratively with NHS colleagues through the Mental Health Urgent & Emergency Care Board and Mental Health Urgent & Emergency Care Improvement Plan to help inform what the new provision could look like. 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. Whilst Sussex Police are an active participant in the review, SPFT retain the latest information regarding timescales, service specification and service scope. Mental Health Training at Sussex Police You would like to understand more about mental health training for police officers, particularly as PC said she could not recall receiving any updated mental health training since starting 7 years ago, noting she is in training role. The subject of mental health has been a particular training focus for Sussex Police for some time. Training has already been rolled out across the force in many areas and is detailed in the enclosed supplementary statement of , the Mental Health Lead for Sussex Police.

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. As part of this roll out, additional spaces on these courses will be open to all officers who are longer in service, who will be able to book onto the course, although it will not be mandatory for them. This is offered alongside the courses that are currently taught and the learning will be captured on our LEARN platform, allowing a full record of completion to be captured for each learner. 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:
• Coaches on Divisional Coaching Units
• Trainers in Initial training (though most deliver mental health training or are Mental Health First Aiders)
• Assessors in the Assessment & Verification Team
• Special Constables
• Investigating Officers
• PIP 2 Investigators

Compliance will be monitored, and the College Learn Platform is only accessible via individual login. Our L&PD department is currently working hard to ensure this is introduced as soon as possible, and the urgency for this training has been highlighted and escalated accordingly. Available Resources around Mental Health There is a myriad of information available to officers and staff on their individually issued MDTs (Mobile Data Terminals). The information provides guidance for officers via an app- based system and can be easily accessed whilst they are attending incidents. This includes, but is not limited to: Crew Mate:
• Suicide Intervention

• Mental Health Guide – broken down into two clear sections: o Section 136 of the Mental Health Act 1983 - A&E Response Guide o Full Mental Health Guide

Quick Links:
• Mental Health Form
• Crib Sheet for completion of the Mental Health Form - this is a guidance document detailing when and how to use the form, in relation to the following situations: o Section 136 o Section 135 Warrant o Voluntary Attendance/Referral to Mental Health Services o Mental Capacity Act
– Mental Health Training It is accepted that PC ’s mental health training may not be as up to date as it should be. As referenced in ’s statement, from October 2021 – March 2022, there was an input on mental health at Personal Safety Training (PST) and PC attended her refresher PST on 22nd March 2022, and therefore should have received the input on mental health crisis and dealing with distressed victims. PC may have also attended the CPD training sessions, as outlined, again, in ’s supplementary statement. However, as has been identified, attendance at the training is not always captured. I am pleased to say that steps have been taken to address this issue, and going forwards, attendance will be recorded. 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. Crucially, from the 7th October 2024, staff on DCU will become part of our Neighbourhood Policing Teams and therefore mandatory training will become aligned. We are grateful that Ryan’s Inquest identified this issue for us, and we have now taken steps to address training for roles that may otherwise have not been included in the mandatory training. has offered 1:1 training to PC , which will provide a refresher on mental health, as well as address any knowledge gaps. As identified above, the planned roll out of “Mental Health and the Police” (College of Policing package) will ensure mandated mental health training is provided to all officers and staff that may be required to attend incidents where mental health could be a factor. PC Hunt and her colleagues in the DCU will be included in this training going forwards. I hope the additional information provided herein reassures you that your concerns have been addressed. As an organisation, we remain committed to learning and improving our processes wherever we can. Please do let me know if I can be of further assistance.

Dear HMAC Robert Simpson, Re: Inquest into the death of Ryan Ouslem I write in response to the Regulation 28 report dated 24th September 2024, issued after the conclusion of the inquest touching upon the sad death of Ryan Ouslem. We are grateful to you for providing us with a further opportunity to respond to the concerns that relate to Sussex Police, and hope this response provides you, and Ryan’ s family, with the information and reassurance from us that when concerns are highlighted, they are carefully considered and actioned as appropriate. I address each of the Sussex Police related concerns below. Mental Health training for Officers in Sussex Police Following evidence provided by an officer during the inquest and our letter to you dated 18th September, you remain concerned that the current provision of mental health training has not been effective and is not repeated as often as required. We have previously provided, by way of a statement from , Force Mental Health lead dated 17th September 2024, and our letter to you dated 18th September, the number of ways new & existing officers receive training relating to mental health and their powers and obligations when dealing with those in crisis. We include these with this response for ease of reference. Our letter & ’s statement outline our existing offering and we do not look to repeat the content here but would ask that they are read in conjunction with this letter. New Officer training 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. We attach the content of this training for your information as follows: Appendix 1 – Wellbeing & Resilience PCEP Lesson Plan Appendix 2 – Legislation – Mental Health Lesson Plan

HMAC Robert Simpson 27/11/2024

Appendix 3 – FAA L3 Mental Health Session Plan Appendix 4 – PCDA Mental Health Lesson Plan Appendix 5 – PCSOA Mental Health Power point presentation. Existing Officer training We recognise that the need for ongoing and refresher training is essential in this complex area, and whilst it cannot be expected that officers make clinical judgements, we do require them to understand where updated information and support can be obtained in relation to clinical decisions and the powers and processes available to them. has explained in his statement the existing training currently provided to assist. In addition, Response & Neighbourhood officers attend 5 Professional Development Days (PDD’s) throughout the year, during which mental health training can be included. These mandatory training days are allocated as part of their shift pattern to ensure attendance. Virtual sessions are recorded and it is expected that those unable to attend through sickness or leave to review the recordings. The content and subject matter of these PDD’s is flexible, allowing the time to be used based on priority and any potential learning gaps that have been identified. To this end, mental health awareness training has been included, with specialist inputs being provided by our Mental Health team and our wellbeing lead. 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). Existing officers therefore receive training on mental health at least once a year, often more frequently, as the result of various ways in which inputs are delivered. If they have been unable to attend any of the offered sessions, they are required to complete a national e-learning package, ‘Mental Health and the Police’ to ensure their knowledge remains current. Monitoring individual attendance and training We recognise that, when giving her evidence at Ryan’s inquest, the tutor officer was unable to recall specific training that had been provided to her and understand the concern and lack of confidence in our training provision that this resulted in for yourself and Ryan’s family. This officer was deeply affected by Ryan’s death and found providing in-person evidence distressing. Whilst we do not criticise that officer in any way, we believe this led to her vagueness and confusion.

HMAC Robert Simpson 27/11/2024

As a result, we identified that we were unable to confirm exactly what training this officer had personally received, whether she had missed sessions or whether her training was current. As this was the case for this officer, we are also concerned it may be for others. This is something that we are very keen to address going forwards to ensure all officers are attending training that they are required to complete. Historically, attendance at training is recorded locally, often by those delivering the training and there is reliance on supervisors to advise our training team who has and has not attended. This has made monitoring compliance and providing places to those who have missed training difficult. 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. We expect to have current records entered and the system fully operation for all existing officers within the next 9-12 months. Our learning and development team, along with supervisors, will be able to access this system and ensure that required training for individual officers is both up to date and fully compliant. Where training has not been completed, places will be offered on the next course and the officer will be expected to watch the recorded session in a timely manner.

Mental Health Services and joint training with the police You have raised concerns that under the new ‘Right Care, Right Person’ policy, the lack of joint training may lead to officers not understanding what information should be provided to ensure all relevant information is shared. We absolutely agree that police officers still need to understand and be trained in mental health matters to ensure they accurately assess situations when calls for service are received or attending those who may be in mental health crisis, despite the new way of working. To that end, our training provision, as outlined above and in our previous correspondence, will not diminish or be reduced. 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.

HMAC Robert Simpson 27/11/2024

However, following Ryan’s inquest, discussions have been held with our SPFT partners to see if any support can be provided to either organisation from the other in relation to training. These discussions are ongoing. Officers are currently required to contact the Blue Light Line (BLL) when dealing with an incident in which they believe mental health is a factor and will continue to do so with the introduction of the SPFT Rapid Response Service (RRS). The BLL provides clinical advice and guidance to police officers who are dealing with an incident. The sharing of information takes place by telephone, when on-scene. Officers speak to a clinician during this call and are expected to share information about the presenting situation in line with data protection legislation, the National Decision Making model and the College of Policing Mental Health Authorised Professional Practice. Officers will relay all information available to them, as well as the situation as it is presented with the aim of helping the clinician understand the totality of the circumstances. Officers will answer questions asked by the clinician to the best of their ability. Police Officers are not, nor can they be expected to be, mental health clinicians and are unable to perform clinical assessments on individuals. They are reliant on the clinicians on the BLL to give appropriate clinical guidance and complete clinical decision making. The Authorised Professional Practice on Mental Health states: ‘Police officers are neither trained nor equipped to carry out clinical assessments on the mental health or wellbeing of an individual (no matter how urgent the issue is) and it is not appropriate for them to fulfil the role of healthcare professional’. Officers are required to share all available permissible information about the presenting situation when utilising the blue light line. We recognise that officers may not know what is clinically relevant or not so are therefore encouraged to provide as much information as they can. The provision of detailed information allows the clinicians to receive the full picture of the incident as it is occurring and ask questions for further details on what they believe is relevant in the circumstances. We put out regular briefings on the importance of using the Blue Light Line (the most recent can be found at Appendix 7). Further, our SPFT partners are developing a Standard Operating Protocol for the RRS to provide guidance to officers who contact them for advice & assistance. This be shared with us once completed and will be communicated to all officers. It will ensure officers are aware of the expectations placed upon them when contacting the BLL and how they can best support the clinicians with whom they are speaking. I hope the additional information provided herein reassures you that your concerns have been addressed.

HMAC Robert Simpson 27/11/2024

As an organisation, we remain committed to learning and improving our processes wherever we can and please do let me know if I can be of further assistance.

Dear Mr Simpson

Inquest into the Death of Ryan Ouslem, Regulation 28: Report to Prevent Future Deaths

I write in response to your Regulation 28 Report dated 24 September 2024.

I was so sorry to read the details of the circumstances leading to Ryan's death and I extend my sincerest condolences to his family.

I acknowledge and understand the concerns that you have raised regarding the importance of sharing risk information with Sussex Police as the trust moves from the Street Triage model to the Rapid Response Service (RRS).

I do of course share your concern that for the new RRS to be a success it relies upon joint working with partner agencies to ensure as far as possible, that our approach to assessing risk of a vulnerable person in need of mental health support, are aligned.

Your Concern The 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 with 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.

Office of the Chair & Chief Executive Trust Headquarters Portland House 44 Richmond Road Worthing West Sussex BN11 1HS

Prior to the launch of the RRS, representatives from the Trust met with Sussex Police's Mental Health Lead and a representative from West Sussex Fire and Rescue Service on 16 July 2024 which enabled a discussion of how it was anticipated the RRS would function when launched on 4 November 2024. One of the conclusions from the meeting was that there is scope for improvement of the flow of information between the police and mental health services and I address below the action the Trust has taken (and will continue to monitor) to make these improvements.

Improving the flow of information between Sussex Police and RRS Under the previous Street Triage model, it was always the case that there was a discussion between a Mental health practitioner and the police in order to consider whether the use of the Police S136 detaining power (under the Mental Health Act 1983) was appropriate and this would necessarily include discussions around risk.

The soft launch of the RRS went live on 4 November 2024.

The RRS is accessed by a single point of contact (SPOC) which will allow for:
• Consistency of guidance provided to the police;
• Consistency of approach to information sharing;
• A single point for any issues to be identified and corrected.

These benefits were less likely to be available under the previous Street Triage model because each locality developed local practices (e.g. to better support the demographic and to address known risks) and whilst there is still a place to be sensitive and aware of demographic differences and known risks, we recognise the importance of having a trust wide consistent approach in other areas, including how risk information between SPFT and Sussex Police is shared.

A trust wide Standard Operational Procedure for the RRS is being developed which will provide guidance to staff working within the RRS. This will embed the expectations placed

upon our stakeholder partners namely Sussex Police, British Transport Police and South East Coast Ambulance when contacting the RRS. As would be expected, it will also provide guidance around risk management and will include the following:
• An acknowledgment of risk management being a crucial part of the Practitioner's role and responsibilities;
• A requirement that all risks should be clearly documented and accompanied by the source of the information;
• A requirement that all decisions made are based on risk and clinical presentation, be evidenced based and clearly documented and recorded in line with Trust polices.

Joint Training The trust is not commissioned to provide training to Sussex Police and they employ their own Mental Health specialist. However I wish to assure you that this is not a bar to the Trust providing support to Sussex Police with mental health related training. I am able to advise you that immediately following the inquest, the Trust contacted Sussex Police to open the door to discussions about how we may approach cross training and these discussions are ongoing.

I do hope that this response will be of assurance to you and Mr Ouslem's family that the newly implemented RRS provides the trust with an opportunity to monitor the sharing of information between SPFT and Sussex Police prior to it being rolled out across the whole of the trust. If you have any questions regarding the content of this response or if I can further assist please do not hesitate to contact me.