Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0137, written 7 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2020 |
|---|---|
| Reference | 2020-0137 |
| Deceased | Mark Mallinson |
| Coroner | Robert Simpson |
| Coroner area | West Sussex |
| Category | Police related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Constable, Sussex Police 1 CORONER I am ROBERT SIMPSON, assistant coroner, for the coroner area of WEST SUSSEX 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 18th December 2018 an investigation into the death of Mark Oliver George Mallinson, aged 30, was opened. The investigation concluded at the end of the inquest on the 4th February 2020. The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH On the evening of the 2nd December 2018 it was alleged that Mark Mallinson had breached the terms of a restraining order to which he was subject. Sussex Police initially sought to arrest Mark Mallinson. Over the following 4–5 hours Mark Mallinson made numerous threats to take his own life. As soon as Sussex Police were made aware of these threats Mark Mallinson was designated as a high risk missing person and dealt with accordingly. Mark Mallinson had telephone contact with a number of police officers during this period as well as significant telephone contact with family members whilst police officers were present. At some time between 03.20am and 04.24am on the 3rd December 2018 Mark Mallinson committed suicide. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – provided a statement about the training given to police officers in the area of suicide intervention. package for new recruits. This training is designed to give first responders pointers to save lives and to buy time. stated that he had created a training I received further information during the course of the inquest that most new recruits of Sussex Police in the last 12-18 months had received the training. However this training is not being rolled out to the remainder of the police force. The concern I have is that training specifically designed to save lives is not being provided to all front line staff. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd April 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family of Mark Mallinson and I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 7th February 2020 Robert Simpson, Assistant Coroner 2
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