Miles Hurley

Dear Ms Henderson

Re: Regulation 28 Report to Prevent Future Deaths – Mr Miles Ethan Hurley who died on 10 July 2022.

Thank you for your Report to Prevent Future Deaths (hereafter ‘Report’) dated 09 July 2024 concerning the death of Miles Ethan Hurley on 10 July 2022.

In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Miles’ family and loved ones. NHS England is keen to assure the family, and the Coroner, that the concerns raised about Miles’ care have been listened to and reflected upon.

Matters of concern and response:

My response below focuses on those concerns that fall under the remit of NHS England, relevant to the Liaison & Diversion service that we commission, and I have addressed specific points in turn.

1. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Miles’ mental health difficulties to assist in determining the most appropriate care.

The NHS England national Liaison and Diversion (L&D) service specification (at 2.7), published in 2019, places a requirement on all L&D services to provide timely and relevant information to the police to inform bail, charging and disposal decisions, and to advise on the use of any reasonable adjustments, in language that is understood by the police. The specification is silent on the method of sharing that information, as police forces across the country use several different information technology (IT) platforms and systems to record case information.

A Home Office (HO) CoLab research team, which is a team of designers, researchers and technologists collaborating closely with people affected by Home Office policies and services, as well as front-line staff, subject matter experts and practitioners from a variety of other disciplines, recently conducted a cross-government review of L&D services. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

21/08/2024

From that review, the following recommendation regarding how L&D services should share information with police forces was made.

‘NHS England to provide clear guidance to practitioners on what information should be uploaded to police custody logs to ensure consistency and relevance for decision- makers (e.g. custody welfare, bail, police and court outcomes). To be achieved in collaboration with the CPS and local police services.’

The research / review was designed for policy development purposes and is not published.

NHS England has committed to working with the National Police Chiefs’ Council (NPCC) and the Crown Prosecution Service (CPS), to develop a standard template and guidance on how relevant information gained from L&D assessments will flow to the police (similar to an existing L&D Court Report template agreed with the judiciary and His Majesty’s Courts and Tribunal Service (HMCTS) as to how information flows to courts).

2. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.

This is also covered in my response to points 4 and 5 below. The responsibility for the care of those in mental health crisis, requiring the development and delivery of a ‘care plan,’ rests with the Police Custody Healthcare (PCHC) service, who will be able to respond more fully to this point.

PCHC services, commissioned by Police and Crime Commissioners, are responsible for the physical healthcare of detainees and for those in mental health crisis who are detained within police custody suites, which includes the issue of intoxication. PCHC services operate 24 hours a day.

Where a L&D service has engaged with a detainee, they should share any relevant information with the PCHC service to assist that service in any formal mental health assessment or care planning process.

3. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained.

The Faculty of Forensic and Legal Medicine (FFLM) of the Royal College of Physicians provides a clear set of guidelines that address, inter alia, how PCHC services should approach the issue of conducting mental health assessments where detainees with substance use disorders may be intoxicated. The guidelines may be accessed HERE

Responsibility for responding to issues of intoxication and for providing advice to the police on an individual’s fitness to detain, fitness for interview and for conducting pre- release assessments lies with the PCHC service.

4. A lack of guidelines to support an LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability.

NHS England does not publish clinical guidelines specific to the delivery of L&D services. My response to point 3 above provides further detail regarding clinical guidelines.

If an individual is perceived to be in mental health crisis, and in need of an assessment, responsibility for conducting that assessment falls to the PCHC service.

5. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.

As already mentioned, PCHC services, commissioned by Police and Crime Commissioners, are responsible for the physical healthcare of detainees and for those in mental health crisis, who are detained within police custody suites, which includes the issue of intoxication, and these services operate 24 hours a day.

L&D services, commissioned by NHS England, respond to those individuals with a wide range of vulnerabilities. They conduct assessments and, if needs are identified, they will look to make supported referrals into relevant and appropriate community services. With the detainee’s consent, L&D services will share information with key decision makers within criminal justice agencies, such as the police, CPS, defence, court and probation. L&D services do not provide treatment. Most L&D services operate within police custody for 12 hours a day, 7 days a week.

The NPCC maintains a national service specification for PCHC services. NHS England maintains a national service specification for L&D services. Both specifications are written to align and provide clarity as to which service is responsible for specific functions. The function of responding to those in mental health crisis is specifically included within the PCHC specification and is specifically excluded from the L&D specification.

6. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult.

As per the response to points 4 and 5 above, PCHC Services are responsible for advising the police force on the issues of intoxication and mental health crisis.

7. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services.

Your Report raised that evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.

Anyone can make a referral into an L&D service, and this includes self-referrals or referrals from family members or friends. L&D services will actively engage with those who are able to provide relevant information to assist with the assessment and care of a patient. I note that the information shared by the family with the Sussex Partnership Trust Mental Health Helpline was not shared with the NHS England commissioned L&D service and would suggest the Sussex Partnership Trust Mental Health Helpline is best placed to provide a response in relation to this.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Miles, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear HMAC Karen Henderson, Re: Inquest into the death of Miles Hurley I write in response to the Regulation 28 report dated 9th August, issued after the conclusion of the inquest touching upon the death of Miles Hurley. We are grateful to you for providing us with the the opportunity to respond to the concerns that relate to Sussex Police, and hope this response provides you, and Mile’s family, with the information and reassurance that when concerns are highlighted, they are carefully considered and actioned as appropriate. I address each of the Sussex Police related concerns below in turn (numbering follows those within the Regulation report):
1. Lack of effective communication between Police Officers This concern arose when it appeared that there was no formal written handover of Miles’ care whilst in custody. Sussex Police adopts, and follows, the College of Policing Professional Practice guidance in relation to handover procedures. We have included this guidance to assist: ‘It is essential that enough time is allowed for a full and effective briefing and debriefing between custody officers and staff when handing over responsibility for detainees, particularly at shift change over. This ensures that all relevant information is passed on and understood by the person taking over responsibility. If handover has to take place in or around the booking-in desks, the custody suite should be cleared of other personnel. Custody officers and other custody staff should carry out the handover together. Officers and staff should communicate information verbally. Where CCTV exists in the custody area, handover should take place in sight and sound of an appropriate camera and microphone. If CCTV is not available, there should be written acknowledgement that all custody officers and staff have been fully briefed on the risks and needs on each detainee’s custody record. The information entered should include the risks, disabilities, medical needs, vulnerabilities, emerging issues, control strategies and welfare needs of each detainee.

It should also cover the status of each investigation, including the actions required to achieve effective and lawful resolution of the matter for which the person has been detained. The incoming shift of custody officers and staff must ensure that they are aware of all of this information. Custody officers should ensure that rousing checks are completed on all detainees during, or as soon as practicable after, handover. Where multiple custody officers are on duty, each must be aware of their individual duties and responsibilities and ensure that this information is recorded and kept up to date. Local force policy may provide clarity about who is acting as the designated custody officer for each detainee at any given time. Current Sussex Police handover procedures The Principal Sergeant within Custody is responsible for managing the custody centre, and has oversight of the safety, welfare and dignity of detainees in their care. This is a responsibility that is taken very seriously and is carried out by an experienced and trained Principal Sergeant who is guided by the HMICFRS direction that ‘it is incumbent on all police officers and police staff to ensure that information relating to threat, harm and risk is passed on to the appropriate officers and other persons responsible for the care and wellbeing of the detainee’. At the point of handover, the Principal Sergeant will refer to a handover document (a copy of which is supplied at Appendix 1) from which they will brief the oncoming team verbally. All members of the current duty team and the oncoming team will be present. They are each given a copy of the handover document which they can refer to during the briefing. The briefing is delivered by the Principal Custody Sergeant in person and is recorded on CCTV which is accessible at any time. The handover document is a live document which is updated by the Principal Sergeant throughout their shift. The document contains a summary of each detainee, highlights risks and mitigating actions, including engagement with Health Care Professionals, and Liaison and Diversion (LDS) Nurses in Custody. The document is saved in a shared drawer on Sharepoint and is accessible to all custody staff on duty. Following handover briefing a new document is started by the oncoming shift to ensure that there is an audit trail. New Custody Officers are familiarised with the process during their initial training/ mentoring. The quality of the handover document is peer reviewed at the point of handover to ensure it captures the necessary information. The verbal briefing provides the opportunity for any questions to be asked, or clarification to be sought, by the oncoming shift in addition to what is recorded on the handover document to ensure a full understanding of the risks and background of each detainee.

2. Lack of relevant Documentation by the Police During Miles’ custody, his family raised their worries about his deteriorating mental health with officers and other partners. The inquest found that although this was generally passed on and known about by the custody staff, there was no formal record of these concerns. We hope the information provided below assists with understanding how such concerns are now recorded. Sussex Police follows guidance contained within the College of Policing APP ‘Detention and Custody Risk Assessments.’ A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s). The Risk Assessment and Care Plan form part of the Custody Record and are accessed via NICHE (our central recording system). NICHE is set up to automatically create a new Care Plan whenever a review of the detainee’s welfare takes place. Regular reviews are completed throughout a person’s detention to ensure that new information or a change to their physical or mental health is recorded and responded to. Information received from families (such as in Miles’ case) will now be added to this care plan to ensure a record is kept. Detention Officers will carry out regular welfare checks in accordance with the Care Plan and note the outcome of those checks on the Custody Record. They verbally update a Custody Sergeant regarding a change in risk, in addition to noting that change on the custody record. Liaison and Diversion Nurses (LDS) work in Custody between the hours of 08:00hrs and 20:00hrs. They have access to NICHE and their own portal and will proactively triage detainees in Custody. They will provide advice and guidance to the Custody Sergeant regarding the risks associated with an individual in Custody. Health Care Professionals (HCP) work in Custody and are available 24/7. They will contribute to a detainee’s Risk Assessment and Care Plan on request. They will provide advice to Sussex Police Custody Officers regarding the risks associated with an individual in Custody, their Care Plan and their Release Risk Assessment. LDS Nurses and HCPs have access to NICHE, enabling them to both review existing information and add additional notes. They update the Custody Record directly and will record the relevant points around risk and their recommendations on the Custody Record. A standard Pre-Release Risk Assessment is used to identify risks that may be presented to an individual upon their release from custody. The template is on NICHE (See Pre-Release Risk Assessment, Appendix 2).

If we consider their release to present a risk to their wellbeing, then we will ask the HCP to complete a Fit to Release Risk Assessment. The request is made where the physical or mental health of a detainee has changed. MITIE Healthcare are contracted to complete the Fit to Release Risk Assessment. In that risk assessment detention under S136 Mental Health Act 1983 may be considered. A Child to Notice form will be completed by the Investigating Officer in all cases where a child or young person has been detained in Custody and shared with the local authority. In the case of a Vulnerable Adult a Vulnerable Adult Referral will be completed by the Investigating Officer and shared with the local authority.

3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.

The Liaison and Diversion Service is provided by Midlands Partnership Foundation NHS Trust. At the time of this incident the service was provided by Sussex Partnership Foundation NHS Trust. Health Care Professionals are employed by MITIE Health Care. LDS Staff and HCPs are co-located with Police Custody Officers in each Custody Centre. LDS Nurses will proactively triage detainees listed on the Custody White Board between 08:00hrs and 20:00hrs. This is a virtual white board accessed via NICHE which LDS nurses can independently access at any time. It contains details of all detainees in each Custody Centre. A Professional Discussion will be held between the LDS Nurse and Principal Sergeants to identify assessments that may need to be prioritised. During LDS operating hours Custody Sergeants will verbally flag risks or concerns to them around the physical and/ or mental health of a detainee as soon as reasonably practicable, but generally at the time of booking in. LDS will also consult their Health Care Portal and raise any issues to the Custody Sergeant. Any concerns or risks discussed will be recorded by the Custody Sergeant on the Risk assessment and care plan within the custody record. LDS Nurses can only see a detainee with permission from the Custody Sergeant. Generally, LDS will also make an entry on the CR Detention Log themselves and they will bring any concerns/ considerations to the attention of the Custody Sergeant so that their care plan can be reviewed in accordance with new information.

4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie

The draft MOU provided left concerns from you that it did not adequately address the practical issues facing the LDS and police to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in custody. The concern raised goes on to say: there is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information”. We have reviewed the current operating procedures and guidelines regarding when to obtain a mental health assessment if the individual is intoxicated, and the following provides the process and/or gives guidance to Sussex Police:

1. Officers and staff in custody are required to record identified risks and control measures, per PACE Code C, paragraph 3.8.
2. The custody officer is also responsible for the detainee receiving appropriate clinical attention. If a healthcare professional is required, the custody officer shall ask their opinion on risks/problems, when to carry out an interview and safeguards per PACE Code C, paragraph 9.13.
3. There is APP Guidance from the College of Policing on detention and custody risk assessments (appendix 3)
4. There is APP Guidance on alcohol and drugs (appendix 4)
5. There is APP guidance on mental vulnerabilities and illness (appendix 5).

The APP guidance is therefore clear that:
• Decision making concerning health care matters should be made by clinically trained professionals and not police officers;
• Officers and staff must risk assess detainees throughout their detention; and
• Officers must always consult a health care professional in prescribed circumstances regarding those who appear intoxicated.

We have very carefully considered the need for a MOU between the operating partners, reviewed the guidelines already in place, sought independent legal advice to assist with our decision making and assessed whether an MOU could assist. We have concluded that we do not believe it is the correct approach in the circumstances.

We believe creating a MOU would be a disadvantage due to it codifying, in a separate document, procedures that are already stated in National Guidance. This could be problematic should the National Guidance change and/or there could be a perceived conflict between the existing guidance and the MOU.

We understand that this is a different position to that taken during the latter stages of the inquest and we do hope we have explained why. Changes to guidance could not be adopted as quickly by Sussex Police should a MOU exist and we would prefer to work

closely with our partners in a practical and realistic way, addressing concerns as they arise as opposed to being led by a MOU that could quickly become outdated.

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 and please do let me know if I can be of further assistance.

Dear Madam, Reg 28 PFD Report following the Inquest touching the death of Miles Ethan Hurley Further to your letter dated 9th August 2024 enclosing a copy of the Regulation 28 Report to Prevent Future Deaths in this matter (the “PFD Report”), we set our response below. PFD Concerns We note that the Coroner has identified the following concerns, namely:
1) Lack of effective Communication between police officers
2) Lack of relevant Documentation by the Police
3) Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
4) Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie, and specifically in relation to this point - “The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.” The Mitie Care & Custody Service For context, and by way of assistance to the Coroner in these matters, we confirm that Mitie Care & Custody Limited (“C&C”) is the current forensic medical healthcare partner to Sussex Police, through which C&C provides 24/7 365 days a year physical healthcare services to persons detained in police custody, but not mental health services, and at the request of the police will

Mitie Care & Custody Limited The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK

Mitie.com/custodial-services Mitie Care and Custody Limited is registered in England under company number 6976230 at The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK

perform forensic medical examinations for the purpose of gathering evidence, and will also conduct various assessments such as ‘fit to detain’ and ‘fit to release’. During our assessments, if we become concerned for an individual’s mental health, we can refer them to A&E for a non-Mental Health Act assessment, or to AMHP (the approved mental health practitioners) for a Mental Health Act assessment. We can also refer an individual to the on-site Midlands Partnership University NHS Foundation Trust Liaison Diversion Service (the “L&D Trust”) for further vulnerability screening but note that their service is not a 24/7 service and is not a mental health assessment service. We also have access to the Blue Light Line for mental health advice. At all times we are reliant on the information provided to us by the Police, by the L&D Trust where applicable, and by the individual themselves. We do not have access to the individual’s full medical/GP record. Instead, we have access to the individual’s summary care record (via the National Care Records System), which contains a limited amount of clinical information - usually current medication, GP details and known allergies. We also have access to any previous custody clinical records. We also have information sharing agreements in place with the police and other named partners (including the L&D Trust) in accordance with the Data Protection Act. Response to the PFD Report From our careful review of the PFD Report we note that the matters referred to therein, particularly with regards to ‘concern number 4’ as set out above, seek to address specific concerns as to the management and availability of mental health assessments in police custody, to which C&C are not involved. In this instance, we humbly consider that this concern would be most appropriately addressed by the Police, NHS England and its local mental health and liaison and diversion services teams. That being said, we take the matters raised within the PFD Report very seriously and have been liaising collaboratively with Sussex Police (our client) and the L&D Trust to understand our role in any formal process or procedure that they may wish to put in place that addresses these concerns, and in accordance with their responsibilities under PACE and the APP. We remain firmly committed to working with these parties in respect of the development of any standard operating procedures and/or the clarification of the mental health referral pathways, as may be required, in order to ensure that we abate any concerns you may have on this point. We hope that the above is of assistance to HM Coroner.