Miles Hurley

Karen Henderson 
Assistant Coroner 
HM Coroners Service West Sussex, Brighton and Hove 
Parkside Chart Way 
Horsham 
RH12 1XH 

By email: 
Copy to: 

Dear Ma’am 

Trust Headquarters 
St George's Hospital  
Corporation Street 
Stafford ST16 3SR 

www.mpft.nhs.uk 

27 September 2024 

Regulation 28 Report to Prevent Future Deaths regarding the death of Mr Miles Ethan Hurley 

I am writing to you on behalf of Midlands Partnership University Foundation NHS Trust (MPFT) in response 
to your Prevention of Future Deaths report dated 9 August 2024, following the inquest touching the death 
of Miles Ethan Hurley. 

At the outset I would like to express my sincere condolences on behalf of MPFT to Mr Hurley’s family and 
friends. 

This letter is MPFT’s formal response to your PFD report. 

A Liaison and Diversion service has been operating in Sussex since 1993.  The Liaison and Diversion Service 
assesses vulnerable individuals with complex needs being brought into the criminal justice system, having 
been suspected of criminal activity.  Until 1 April 2024 this service was delivered by Sussex Partnership NHS 
Foundation Trust (SPFT).  MPFT are aware that during the time the service was delivered by SPFT there was 
an established good working relationship between Sussex Liaison and Diversion Service (SLDS), Sussex 
Police and Mitie.  The Liaison and Diversion Service transferred to MPFT on 1 April 2024 and MPFT have 
taken steps to ensure that this good working relationship is maintained. 

Custody Pathway Standard Operating Procedure 

Since assuming responsibility for Liaison and Diversion services in Sussex MPFT has introduced a Custody 
Pathway - Standard Operating Procedure (SOP).  The SOP was written by Operational Managers/clinicians 
experienced in the delivery of Liaison and Diversion services in Police custody and was implemented in 
June 2024. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The SOP outlines staff responsibilities including an expectation that staff:  

•  Share information with the Police in writing by recording information directly in the local Police 

records system or, where staff do not have read/write access, by email to the responsible Custody 
Sergeant to include in the Police written records.  MPFT staff working in SLDS have read/write 
access to the Sussex Police record system enabling them to record information directly into the 
Police system 
Include a clear, written plan to address any vulnerabilities identified, including mental health 
difficulties, with a rationale for the proposed care/actions 

• 

•  Consider their duty of care to individuals and share relevant risk information with Police colleagues, 
including in circumstances where consent is withheld or cannot be obtained if the degree of risk 
warrants the sharing of the information. 

In direct response to your concerns raised during the inquest into Mr Hurley’s death regarding the lack of 
guidelines to support a Liaison and Diversion 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, MPFT are currently reviewing the Custody Pathway SOP.  It has been agreed with the Senior 
Leadership Team in MPFT Health and Justice Services that written guidelines, regarding assessment of 
individuals who are intoxicated, are needed for MPFT staff.  MPFT Custody Team Leaders are meeting on 
the 9th October 2024 to review the SOP to add: 

•  Written guidance for MPFT staff, based on current best practice guidelines, regarding the process 
to be followed in the event that someone in Police custody who has been identified as needing an 
assessment by the Liaison and Diversion team is intoxicated  

•  A standard template to structure the written information to be given to Police colleagues to ensure 

greater consistency and accuracy in the information shared. 

Information Sharing 

Local information sharing arrangements are in place with SPFT to facilitate the sharing of collateral 
information.  Staff working in SLDS have read only access to SPFT’s electronic patient record system 
allowing them to view details of an individual’s psychiatric history and to determine whether individuals are 
currently, or have been, supported by local services. 

Operating Hours 

In regards to your concerns that there is a lack of a 24 hour Liaison and Diversion service within the custody 
suite SLDS services are commissioned by NHS England Health and Justice.  

The specification for the service in Sussex requires MPFT to provide in-person delivery of the service for a 
minimum of 12 hours per day, seven days a week in all five custody suites.  The SLDS team currently 
provide a service from 8am to 8pm, seven days a week in all custody areas.  MPFT are currently considering 
a plan to: 

•  Extend the service from 8am to 10pm each day 
• 

Introduce an on-call service from 10pm to 8am each day.  The on-call service would be delivered by 
a registered practitioner who would provide advice and consultation to Police and Health Care 
Professionals working in Police custody across Sussex. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Memorandum of Understanding (MOU) 

The Serious Incident Review undertaken by SPFT into Mr Hurley’s death recommended that an MOU should 
be put in place between Sussex Police and SPFT.  The implementation of the MOU, originally drafted by 
SPFT, was put on hold due to the re-procurement of Liaison and Diversion services during 2023.  MPFT 
became aware of the recommendation contained in SPFT’s report in March 2024.  Since its commencement 
of delivering the Liaison and Diversion service MPFT has been working proactively with Sussex Police and 
Mitie to agree the content of a revised MOU.  The revised MOU has been updated by MPFT to include roles 
and responsibilities regarding risk assessments and the management of people in custody who are 
intoxicated.  MPFT has provided input into the content of the MOU, however, the final working of the MOU 
is subject to agreement with Sussex Police and Mitie. 

MPFT met with Sussex Police most recently on the 18 September 2024 to discuss the content of the revised 
MOU and a further meeting is planned on the 27 September 2024 to discuss the revised document with 
Mitie.  It is anticipated that further discussions will be required in order to finalise the content of the MOU 
and MPFT will continue to work proactively with partners to agree the final wording. 

We wish to assure you and Mr Hurley’s family that the actions described above are being taken forward 
with considerate attention.  

Yours sincerely 

Chief Executive Officer

on behalf of HM Assistant Coroner Dr Karen Henderson 

FAO: 
HM Coroners Service 
West Sussex Brighton and Hove 
Parkside Chart Way 
Horsham 
RH12 1XH 

Sent by email to: 

Dear Madam, 

4 October 2024

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. 

Yours Sincerely, 

Medical Director and Caldicott Guardian for Mitie Care & Custody Limited 

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

Karen Henderson 
HM Assistant  Coroner 
West Sussex,  Brighton  and Hove Coroner’s  Office,  
Chart Way Way 
Horsham 
West Sussex 
RH12 1XH  

National Medical  Director  
NHS England   
Wellington  House 
133-155  Waterloo  Road  
London 
SE1 8UG 

21/08/2024 

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. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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.  

Yours sincerely,   

National  Medical Director

HM Assistant Coroner  
Ms. Karen Henderson 
HM Coroners Service 
West Sussex 
Brighton and Hove 
BN2 3QB 

Dear Ms. Henderson, 

3rd October 2024 

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 
5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, in relation to the prevention of future deaths notice regarding the death of Miles 
Ethan HURLEY on 10/07/2022, in my role as NPCC lead for Custody. 

The notice sets out concerns that arose from the information received during the inquest into the 
death  of  Mr  Hurley.  I  am  very  sorry  to  read  of  the  circumstances  of  Mr  Hurley’s death  and  my 
sympathies are with his family and friends.  

Within the Regulation 28 you highlighted four main areas of concern. In my role as NPCC Lead for 
Custody, I will address the first three points. The fourth relates to a Memorandum of Understanding 
between  Midlands  Partnership  University  NHS  Foundation  Trust,  Sussex  Police  and  MITRE, 
therefore, these organisations will be best placed to address your concerns. In relation to the areas 
of concern, please see below: 

1.  Lack of effective communication between police officers 

Concerns were raised regarding a decline in Mr Hurley’s mental health, missing periods and risk 
behaviours that the report states were present at the point of Mr Hurleys arrest but not passed to 
the Sergeant on his arrival in custody.  

The  practice  of  arresting  officers  risk  assessments  being  formally  completed  prior  to  arrival  at 
custody  is  inconsistent  across  forces.  Best  practice  is  being  considered  through  the  NPCC 
Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to 
communicate risks and concerns that may have been raised. 

 
 
 
 
 
 
 
 
 
 
            
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Lack of relevant documentation 

It is recognised that there is a lack of information being recorded on custody detention logs. The 
College of Policing Hydra packages are in place to improve this and the NPCC are supportive of this 
training for custody staff. I understand that Sussex Police have now adopted this training.  

3.  Lack  of  effective  documentation  and  communication  between  the  Liaison  and 

Diversion Service (LDS) and the police within the custody suite. 

I provide comment against each of the sections within this area of concern below: 

a)  This is a local force issue and therefore not for the NPCC to make comment. 

b)  The NPCC is unable to make comment on the mental health plan referred to in this case. 

c)  Guidelines around supporting a LDS Practitioner as to when it is appropriate to undertake a 
formal mental health assessment when an individual is intoxicated is a matter for the LDS 
provider. Whilst it is positive that an assessment was considered in this case, it is unclear 
from the report whether this was a ‘fitness for detention/release’ assessment that was being 
requested. An assessment under the Mental Health Act would require an Approved Mental 
Health Professional to have attended the suite at the request of LDS. LDS practitioners are 
mental health professionals, and it is within their remit to conduct such an assessment and 
therefore not for the police to make comment. 

d)  A lack of 24-hour LDS service is an issue that has been raised previously with NHSE by the 

NPCC as an area of concern. 

e)  National  guidelines  are  in  place  in  the  form  of  PACE  Code  C  in  relation  to  identifying 
vulnerability in police custody and the provision of an Appropriate Adult. It is not clear from 
the information in the report as to why the interviewing officer did not deem the support of 
an Appropriate Adult for Mr Hurley necessary in this case. 

f)  NHS Trust information sharing has also been raised as a concern by the NPCC in that the 
inability or refusal to share clinical records between criminal justice pathways adds risk to a 
detainees welfare.  

The  NPCC  continues  to  work  collaboratively  with  key  partners  to  address  concerns  within  the 
custody space and I hope the information provided will go some way to address your concerns. 

Please do not hesitate to contact me if you require further action or information in relation to my 
response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours Sincerely 

Deputy Chief Constable 
Surrey Police 

National Police Chiefs’ Council lead for Custody and the movement of prisoners.

His Majesty’s Area Coroner Joanne Andrews 
West Sussex, Brighton & Hove 

By email:  

30/09/2024 

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. 

information  entered should 

The 
include  the  risks,  disabilities,  medical  needs, 
vulnerabilities, emerging issues, control strategies and welfare needs of each detainee. 

 
 
 
 
 
 
 
 
 
 
 
 Page 2 of 6 

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.  

 
 
 
 
 
 
 
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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).   

 
 
 
 
 
 
 
 
 Page 4 of 6 

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 

 
 
 
 
 
 
 
 
 
 
 Page 5 of 6 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 6 of 6 

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.  

Yours Sincerely  

A/ACC Local Policing