Prevention of Future Deaths reports · 2020

Mark Mallinson

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 report7 Feb 2020
Reference2020-0137
DeceasedMark Mallinson
CoronerRobert Simpson
Coroner areaWest Sussex
CategoryPolice related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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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