Jack Taylor

Dear Mr Simpson Inquest into the death of Jack Taylor I write in response to your Regulation 28: Report to Prevent Future Deaths dated 28 January
2022. I was saddened to learn of the circumstances surrounding Mr Taylor's death and, on behalf of Sussex Partnership NHS Foundation Trust (SPFT), extend our sincere condolences to his family and friends. Following Mr Taylor's inquest, SPFT has been working with Sussex Police to identify changes needed to address the concerns that were raised during the inquest and, subsequently, captured within your Regulation 28 Report. Below is the joint-response to paragraph 2 of your report, agreed between SPFT and Sussex Police. Sussex Police will be writing to you separately to confirm their agreement and to provide you with their response to paragraph 3 of your Report. The joint SPFT & Sussex Police 'Absent without Leave' (AWOL) Policy: A working group was established with healthcare professionals from Mill View Hospital and officers and staff from Sussex Police with the remit to improve the joint response to incidents of patients who are absent without leave. The working group is proposing several solutions to the problems identified and is working towards implementing these jointly. These solutions include: Office of the Chief Executive Trust Headquarters Swandean Arundel Road Worthing West Sussex BN13 3EP

Developing a Missing Persons Template (including an action plan) To improve information flow and joint assessment of risk, work has commenced on co- developing a ‘Missing Persons Template’ to be used by hospital staff to share all relevant information about a potential missing person with Sussex Police in a timely manner. A literature review has been undertaken to identify how other localities implement such templates and this will be used to complete a first draft of the template in April. Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision. The multi-agency review and revision is overseen by Sussex Partnership NHS Foundation Trust (SPFT)'s Mental Health and Mental Capacity Acts Committee and the Mental Health Portfolio within Sussex Police who will collectively have responsibility for ensuring timescales are adhered to and changes are successfully implemented. Additionally, to improve information flow and the overall response to missing persons, it was agreed that work would commence on co-developing a joint missing persons action plan so both agencies can agree actions and tasks in relation to finding a missing person proportionate to the presenting risks. The joint action plan will be developed alongside the missing persons template with a first draft being ready in April. Work will then take place to ensure this is embedded into the new AWOL Policy and practice, anticipated to be complete by May. Proactive Approach to Managing Missing Patients Work has been identified to improve how both Sussex Police and SPFT take a more proactive approach to managing patients who could go missing. SPFT will invite Sussex Police's Missing Person Team to proactively meet to discuss patients who can present with a heightened risk of going missing or becoming absent without leave. This approach is likely to be embedded into the revised AWOL Policy however this practice has been adopted immediately by Mill View Hospital and the Brighton Missing Persons Team. These proposed changes, which currently focus on the Psychiatric Intensive Care Unit at Mill View Hospital, will work towards improving joint working and developing an improved joint response to people who go missing from healthcare facilities operated by SPFT.

Regarding the concerns you raise in paragraph 1 of your report, I confirm that SPFT has considered its full range of powers to secure the return of AWOL patients and recognises that:
• at times, SPFT staff have been over reliant on the police to assist with patient return; and
• improvement can be made to how SPFT's resource, both staff and vehicles, is used to return patients.

As indicated above, revisions are being made to the AWOL Policy, including the missing persons template and joint action plan; these will assist SPFT staff to understand what information the police need to inform their decision-making on the allocation of their resources, as well as providing greater clarity on who is responsible for actions as the AWOL incident evolves.

SPFT recognises that police involvement in the return of a patient may be or may become unnecessary and, at times, a patient's return by SPFT staff, rather than the police, can be preferable to some patients. Alternatively, there will be cases where risk is such that the police must be involved in the return, hence the importance of robust risk assessments, clear communication and a dynamic joint action plan.

If it is identified that SPFT are responsible for the return of the patient, then an SPFT vehicle can be used. Specifically, in relation to Mill View Hospital, an SPFT car is available on-site. SPFT is putting in place improvements to the vehicle access and availability arrangements, as a priority, to ensure staff are able to return patients on all occasions where return by the police is not required.

In addition, an improved escalation process has been implemented and added to the AWOL Policy so that SPFT staff are clear about site-wide support available from colleagues when additional resource is required to facilitate a patient's return.

Finally, more generally, SPFT has an ongoing AWOL reduction project which has been led by the team at the Department of Psychiatry in Eastbourne. That team introduced a number of interventions, including an evidence-based rating tool which identifies those most at risk and enables improved risk mitigation. The measures have led to a sustained reduction in AWOLs in Eastbourne, and are being rolled out across the Trust.

I am confident that the above measures and ongoing collaborative working between SPFT and Sussex Police will result in an improved response when patients go missing. We will monitor the improvements and respond to any further changes needed, to best meet our patients' needs. I envisage that it would be helpful to you to see the updated AWOL Policy so, once ratified, I will arrange for a copy to be sent to you. In the meantime, I hope that the content of this letter provides you with the assurances you need to address your concerns.

If I can be of any further assistance then please do not hesitate to contact me.

Dear Mr Simpson, Sussex Police Response to Regulation 28 issues arising from the death of Jack Taylor Thank you for including us within the scope of this notice. I welcome it as it is vital that Sussex Police, and indeed all public authorities, learn from incidents such as this and strive to improve where necessary. I will deal with your concerns sequentially:
1. S18 Mental Health Act 1983 Powers & Mill View Hospital This relates to our partners at Sussex Partnership Foundation Trust (SPFT) and therefore we are unable to comment on it. In the work we have completed in response to your concerns, we have worked closely with our SPFT partners and are advised that they will, of course, be addressing this in their response to you.
2. The joint Sussex Partnership Foundation Trust & Sussex Police ‘Absence Without Leave (AWOL) Policy. We have collaborated with our partners at SPFT to provide a joint response to this concern. A working group was established with healthcare professionals from Mill View Hospital and officers and staff from Sussex Police with the remit of exploring what can be done to improve our approach to jointly responding to incidents of patients who are absent without leave. Through discussion, the working group are proposing several solutions to the problems identified and are working towards implementing these jointly. These solutions include: Developing a Missing Persons Template (including an action plan) To improve information flow and joint assessment of risk, work has commenced on co-developing a ‘Missing Persons Template’ that can be used by hospital staff to share all relevant information about a potential missing person with Sussex Police in a timely manner. A literature review has been undertaken to identify how other localities implement such templates and this will be used to complete a first draft of the template in April 2022.

2 Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will them be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.

The multi-agency review and revision is overseen by SPFT's Mental Health and Mental Capacity Acts Committee and the Mental Health Portfolio within Sussex Police who will collectively have responsibility for ensuring timescales are adhered to and changes are successfully implemented.

Additionally, to improve information flow and the overall response to missing persons, it was agreed that work would commence on co-developing a joint missing persons action plan that can be used so both agencies can agree actions and tasks in relation to finding a missing person proportionate to the presenting risks.

The joint action plan will be developed alongside the missing persons template with a first draft being ready in April 2022. We will ensure that this is embedded into the new AWOL Policy and practice with it being anticipated that this will be completed by May 2022.

Proactive approach to managing Missing Patients Work has been identified to improve how both Sussex Police and SPFT take a more proactive approach to managing patients who could go missing.

SPFT will invite Sussex Police’s Missing Person Team to proactively meet to discuss patients who can present with a heightened risk of going missing or becoming absent without leave.

This approach is likely to be embedded into the revised AWOL Policy, however this practice will be adopted immediately by Mill View Hospital and the Brighton Missing Persons Team.

These proposed changes, which currently focus on the Psychiatric Intensive Care Unit at Mill View Hospital, will work towards improving joint working and developing an improved joint response to people who go missing from healthcare facilities operated by SPFT.

3. Sussex Police’s use of their Missing Persons Policy To further assist with addressing your concerns, a working group was formed consisting of the relevant departments. The purpose of this group is to review, and where required, update, our current working practices. The group includes representatives from the Sussex Police Missing Persons team, the Response teams and the Force Contact, Command and Control department (FCCCD).

Following a detailed review by this working group, five areas were identified for further work and changes to ensure improvements are made. I outline these below:

3.1 – Escalation if resources prevent allocation within 2 hours Where a medium risk missing person report has not had a named officer assigned to progress the investigation within two hours of the report being received, FCCCD will now escalate it to the Divisional Critical Incident Inspector (referred to as Golf 99 – ‘G99’). If that Inspector is unable to identify a suitable resource, it will be escalated to the relevant Critical Incident Manager (‘CIM’).

The primary responsibility for resourcing incidents will continue to sit with FCCCD, however bringing in this contingency allows greater oversight by G99, and the CIM will be able to assist with re-deployment of resources from other Divisions if it cannot be resourced locally.

This has been introduced already.

3.2 Actions when location becomes known

When information is received relating to the location of a missing person and attendance by an officer is necessary, an officer will be assigned to that location in line with the threat, harm and risk presented.

The officer in command of the missing person investigation will now also be notified. This will ensure that if the location is in another Division, as was the case with Mr Taylor, the officer in command can liaise directly with colleagues in other policing areas to seek resource support if needed. If no named officer has been assigned by that time, it is to be escalated to G99, and if necessary, the CIM, to progress.

This change, and that outlined in 3.1 above, will also be written into policy, which is currently under review. We anticipate it being signed-off and update within the next two months.

3.3 Support to Sergeants in command of medium risk missing persons from mental health facilities outside of the Missing Person Team working hours

Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level. The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.

Further, it is recognised that people who are subject to formal assessment and/or treatment under the Mental Health Act could be more vulnerable than other missing people in the ‘medium risk’ category. There is also more likely to be information and intelligence relating to the person held by others outside of Sussex Police, the obtaining and assessment of which are key to ensure our response is proportionate & necessary. Training will be provided to develop their skills and understanding in these areas (detailed in
3.5 below).

3.4 Missing Person Team Terms of Reference to be reviewed The terms of reference to which the missing person team works is to be reviewed by the Force ‘Missing Persons Working Group’.

It is intended that this review will enhance the support that the missing person team already provides to the initial response phase of a missing person investigation.

4 The team has specialist expertise and effective working relationships with many of our partners, providing real benefit to investigations. However, as a small team, cover is not 24/7 so it would not be possible for the team to take on all investigations from first report. The review will consider what, if any, enhancements can be made to assist their colleagues. We anticipate this review will be completed and presented to our Vulnerability Board in April 2022 and any changes that result will take effect immediately.

3.5 Training provided to Sergeants The existing training that is currently provided to Sergeants who oversee missing person investigations will be reviewed by our Learning & Professional Development Team, who are responsible for preparing and delivering training. Current training includes the function of command, assessing threat, risk & harm, setting and monitoring of proportionate lines of enquiry and handover processes. We intend to include now additionally obtaining and assessing information & intelligence (as referred to in 3.3 above). Where the training can be enhanced, additional formal training and/or Continued Professional Development will be introduced.

We anticipate this review to be completed by the end of April 2022. Any additions to training programmes can take some time to implement due to re-writing of and building into existing training cycles. Accepting this, we will be communicating internally about many of these aspects as soon as possible, and whilst not as comprehensive as structured training, it will provide an overview and guidance prior to formal training roll-out.

We have worked hard both internally and with our partners to ensure that we are able to provide a comprehensive and constructive response. We hope you find this to be the case.

As some of the work and changes highlighted above are still in progress, we will be happy to provide you with a further update of our progress in six months, should you find that to be useful.

If there are any follow-up questions about this response, please do come back to me and I will do my best to resolve them.