Ryan Ouslem

26 November 2024 

Dear Mr Simpson 

Office of the Chair & Chief Executive 
Trust Headquarters 
Portland House 
44 Richmond Road 
Worthing 
West Sussex 
BN11 1HS 

Inquest  into  the  Death  of  Ryan  Ouslem,  Regulation  28:  Report  to  Prevent  Future 
Deaths 

I write in response to your Regulation 28 Report dated 24 September 2024. 

I  was  so  sorry  to  read  the  details  of  the  circumstances  leading  to  Ryan's  death  and  I 

extend my sincerest condolences to his family. 

I  acknowledge  and  understand  the  concerns  that  you  have  raised  regarding  the 

importance  of  sharing  risk  information  with  Sussex  Police  as  the  trust  moves  from  the 

Street Triage model to the Rapid Response Service (RRS). 

I do of course share your concern that for the new RRS to be a success it relies upon joint 

working with partner agencies to ensure as far as possible, that our approach to assessing 

risk of a vulnerable person in need of mental health support, are aligned. 

Your Concern 

The new approach under the Right Care, Right Person policy will still need police officers 

to understand mental health issues in order to know when to pass matters on for mental 

health services to deal with and what information to provide. Despite the significant change 

of  working  arrangements  there  does  not  appear  to  have  been  any  joint  training 

undertaken; nor am I informed that any is planned.  I am concerned that the importance of 

sharing  all  relevant  information  will  not  be  understood  unless  each  organisation 

understands what information to provide to the other or what questions to ask. 

Chair: 

                                                                                                                                 Chief Executive: 

Head office: Sussex Partnership NHS Foundation Trust, Portland House, 44 Richmond Road, Worthing, West Sussex, BN11 1HS 

www.sussexpartnership.nhs.uk 

A teaching trust of Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prior  to  the  launch  of  the  RRS,  representatives  from  the  Trust  met  with  Sussex  Police's 

Mental Health Lead and a representative from West Sussex Fire and Rescue Service on 

16 July 2024 which enabled a discussion of how it was anticipated the RRS would function 

when launched on 4 November 2024. One of the  conclusions from the meeting was that 

there  is scope  for improvement of  the  flow of  information  between  the  police and  mental 

health  services  and  I  address  below  the  action  the  Trust  has  taken  (and  will  continue  to 

monitor) to make these improvements.  

Improving the flow of information between Sussex Police and RRS 

Under  the  previous  Street  Triage  model,  it  was  always  the  case  that  there  was  a 

discussion  between  a  Mental  health  practitioner  and  the  police  in  order  to  consider 

whether  the  use  of  the  Police  S136  detaining  power  (under the  Mental  Health  Act  1983) 

was appropriate and this would necessarily include discussions around risk. 

The soft launch of the RRS went live on 4 November 2024.  

The RRS is accessed by a single point of contact (SPOC) which will allow for: 

•  Consistency of guidance provided to the police; 
•  Consistency of approach to information sharing; 
•  A single point for any issues to be identified and corrected. 

These  benefits  were  less  likely  to  be  available  under  the  previous  Street  Triage  model 

because  each  locality  developed  local  practices  (e.g.  to  better  support  the  demographic 

and to address known risks) and whilst there is still a place to be sensitive and aware of 

demographic differences and known risks, we recognise the importance of having a trust 

wide  consistent  approach  in  other  areas,  including  how  risk  information  between  SPFT 

and Sussex Police is shared. 

A  trust  wide  Standard  Operational  Procedure  for  the  RRS  is  being  developed  which  will 

provide guidance to staff working within the RRS. This will embed the expectations placed 

 
 
 
 
  
 
 
 
 upon our stakeholder partners namely Sussex Police, British Transport Police and South 

East  Coast  Ambulance  when  contacting  the  RRS.    As  would  be  expected,  it  will  also 

provide guidance around risk management and will include the following: 

•  An  acknowledgment  of  risk  management  being  a  crucial  part  of  the  Practitioner's 

role and responsibilities; 

•  A requirement that all risks should be clearly documented and accompanied by the 

source of the information; 

•  A  requirement  that all decisions made are  based on  risk  and  clinical presentation, 

be  evidenced  based  and  clearly  documented  and  recorded  in  line  with  Trust 

polices. 

Joint Training  

The trust is not commissioned to provide training to Sussex Police and they employ their 

own  Mental Health  specialist.    However I  wish  to assure  you  that this is not  a bar to  the 

Trust providing support to Sussex Police with mental health related  training.  I am able to 

advise  you  that  immediately  following  the  inquest,  the  Trust  contacted  Sussex  Police  to 

open  the  door  to  discussions  about  how  we  may  approach  cross  training  and  these 

discussions are ongoing.   

I do hope that this response will  be of assurance to you and  Mr Ouslem's family that the 

newly  implemented  RRS  provides  the  trust  with  an  opportunity  to  monitor  the  sharing  of 

information between SPFT and Sussex Police prior to it being rolled out across the whole 

of  the  trust.  If  you  have  any  questions  regarding  the  content  of  this  response  or  if  I  can 

further assist please do not hesitate to contact me. 

Yours sincerely  

Chief Executive

His Majesty’s Assistant Coroner Robert Simpson 
West Sussex, Brighton & Hove 

By email:  

18/09/2024 

Dear HMAC Robert Simpson,   

Inquest touching on the death of Ryan Louis Ouslem  

I write in response to concerns you raised following the conclusion of the Inquest into the 
death of Ryan Louis Ouslem, which concluded on 5th September 2024. We are grateful for 
the opportunity to address these concerns and trust the following information will assist.  

Rapid Assessment Service 

You have requested information from Sussex Police and SPFT regarding plans for roll out 
of  the  SPFT  “Rapid  Assessment  Service”  where  practitioners  from  the  Trust  will  be 
attending police calls which have a mental health element (where requested). In line with 
this, you would also like to know how information is to be shared between agencies.  

The roll out of the Rapid Assessment Service is being led by SPFT who are commissioned by 
NHS Sussex to deliver secondary mental health care in Sussex. Sussex Police are an active 
participant  in  the  review  process  and  are  working  collaboratively  with  NHS  colleagues 
through the Mental Health Urgent & Emergency Care Board and Mental Health Urgent & 
Emergency Care Improvement Plan to help inform what the new provision could look like. 

As  it  stands,  the  Rapid  Assessment  Service  or  Rapid  Response  will  be  accessed  by  our 
officers via the Blue Light Line. The Blue Light Line is already operational, and it is current 
policy to utilise this service when dealing with a mental health incident. The Blue Light Line 
retains records of the contact and ensures information is correctly processed. There will be 
no  change  in  practice  required  for  police  officers  when  the  Rapid  Response  Service  is 
launched, and it anticipated it will enhance the offer of service from the Blue Light Line.  

Whilst  Sussex  Police  are  an  active  participant  in  the  review,  SPFT  retain  the  latest 
information regarding timescales, service specification and service scope. 

Mental Health Training at Sussex Police  

You  would  like  to  understand  more  about  mental  health  training  for  police  officers, 
particularly  as  PC 
  said  she  could  not  recall  receiving  any  updated  mental  health 
training since starting 7 years ago, noting she is in training role. 

The subject of mental health has been a particular training focus for Sussex Police for some 
time. Training has already been rolled out across the force in many areas and is detailed in 
the  enclosed  supplementary  statement  of 
,  the  Mental  Health  Lead  for 
Sussex Police.  

 
 
 
 
 
 
 
 
 
 Page 2 of 4 

Moving forwards, all new Police officers joining Sussex Police via initial entry routes will be 
completing a two-day mental health course, which is an accredited qualification – ‘Level 3 
in  Supervision  of  Mental  Health’.  The  anticipated  rollout  is  from  January  2025  and  the 
qualification will give officers  the opportunity to spend more time on the techniques of 
talking to people presenting with a mental health condition and will involve completion of 
related scenarios. 

As part of this roll out, additional spaces on these courses will be open to all officers who 
are  longer  in  service,  who  will  be  able  to  book  onto  the  course,  although  it  will  not  be 
mandatory for them. This is offered alongside the courses that are currently taught and the 
learning will be captured on our LEARN platform, allowing a full record of completion to be 
captured for each learner.  

Work continues with the Sussex Police Learning & Professional Development Team (L&PD) 
to  roll  out  a  mandated  training  package  via  the  College  Learn  Training  Platform.  As 
referenced in Mr Gordon’s statement, “Mental Health and the Police” is a 90-minute e-
learning package produced by the College of Policing. It was initially rolled out to Response 
Officers in Winter 2021, and Autumn of 2022, but completion will now be mandatory for 
the following officers and staff:  

•  Coaches on Divisional Coaching Units  
•  Trainers in Initial training (though most deliver mental health training or are 

Mental Health First Aiders) 

•  Assessors in the Assessment & Verification Team 
•  Special Constables  
• 
•  PIP 2 Investigators 

Investigating Officers 

Compliance  will  be  monitored,  and  the  College  Learn  Platform  is  only  accessible  via 
individual  login.  Our  L&PD  department  is  currently  working  hard  to  ensure  this  is 
introduced as soon as possible, and the urgency for this training has been highlighted and 
escalated accordingly.  

Available Resources around Mental Health 

There is a myriad of information available to officers and staff on their individually issued 
MDTs (Mobile Data Terminals). The information provides guidance for officers via an app-
based system and can be easily accessed whilst they are attending incidents. This includes, 
but is not limited to: 

Crew Mate: 

•  Suicide Intervention 

•  Mental Health Guide – broken down into two clear sections: 

o  Section 136 of the Mental Health Act 1983 - A&E Response Guide 
o  Full Mental Health Guide 

 
 
 
 
 
 
 
 
 
 Page 3 of 4 

Quick Links: 

•  Mental Health Form 
•  Crib Sheet for completion of the Mental Health Form - this is a guidance document 
detailing when and how to use the form, in relation to the following situations:  

o  Section 136  
o  Section 135 Warrant  
o  Voluntary Attendance/Referral to Mental Health Services 
o  Mental Capacity Act 

 – Mental Health Training 

’s mental health training may not be as up to date as it should 
It is accepted that PC 
’s statement, from October 2021 – March 2022, there was 
be. As referenced in 
an  input  on  mental  health  at  Personal  Safety  Training  (PST)  and  PC 
  attended  her 
refresher PST on 22nd March 2022, and therefore should have received the input on mental 
health crisis and dealing with distressed victims.  

PC 

  may  have  also  attended  the  CPD  training  sessions,  as  outlined,  again,  in 
’s supplementary statement. However, as has been identified, attendance at the 
training is not always captured. I am pleased to say that steps have been taken to address 
this issue, and going forwards, attendance will be recorded.  

It is however accepted that currently, PC 
’s role in the Divisional Coaching Unit (DCU) 
does not necessarily capture all CPD Training and Professional Development Days, as her 
role  is  not  classed  as  a  Response  Officer  nor  Neighbourhood  Policing  Officer,  for  whom 
training is mandated. Officers within the DCU can attend CPD Training but is dependent on 
their awareness that the CPD sessions are being run.  

Crucially, from the 7th October 2024, staff on DCU will become part of our Neighbourhood 
Policing Teams and therefore mandatory training will become aligned.  

We are grateful that Ryan’s Inquest identified this issue for us, and we have now taken 
steps  to  address  training  for  roles  that  may  otherwise  have  not  been  included  in  the 
mandatory training.  

 has offered 1:1 training to PC 

, which will provide a refresher on mental 

health, as well as address any knowledge gaps.  

As  identified  above,  the  planned  roll  out  of  “Mental  Health  and  the  Police”  (College  of 
Policing package) will ensure mandated mental health training is provided to all officers 
and staff that may be required to attend incidents where mental health could be a factor. 
PC Hunt and her colleagues in the DCU will be included in this training going forwards. 

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

 
 
 
 
 
 
 
 
 
 Page 4 of 4 

Yours sincerely, 

Chief Superintendent 

West Sussex Divisional Commander

His Majesty’s Assistant Coroner Robert Simpson 
West Sussex, Brighton & Hove 

By email:   

27/11/2024 

Dear HMAC Robert Simpson,   

Re: Inquest into the death of Ryan Ouslem  

I write in response to the Regulation 28 report dated 24th September 2024, issued after 
the conclusion of the inquest touching upon the sad death of Ryan Ouslem.  

We are grateful to you for providing us with a further opportunity to respond to the 
concerns that relate to Sussex Police, and hope this response provides you, and Ryan’ s 
family, with the information and reassurance from us that when concerns are highlighted, 
they are carefully considered and actioned as appropriate.  

I address each of the Sussex Police related concerns below.  

Mental Health training for Officers in Sussex Police  

Following evidence provided by an officer during the inquest and our letter to you dated 
18th September, you remain concerned that the current provision of mental health 
training has not been effective and is not repeated as often as required.  

We have previously provided, by way of a statement from 
, Force Mental 
Health lead dated 17th September 2024, and our letter to you dated 18th September, the 
number of ways new & existing officers receive training relating to mental health and 
their powers and obligations when dealing with those in crisis. We include these with this 
response for ease of reference.  

Our letter & 
repeat the content here but would ask that they are read in conjunction with this letter.  

’s statement outline our existing offering and we do not look to 

New Officer training 

In addition to the training currently outlined by 
, we are also introducing, from 
January 2025, Mental Health First Aider training to all new recruits. This is comprehensive 
and consists of a number of packages that will be delivered as part of their induction 
course which is bespoke to their future role. Attendance is mandatory.  

We attach the content of this training for your information as follows: 

Appendix 1 – Wellbeing & Resilience PCEP Lesson Plan 

Appendix 2 – Legislation – Mental Health Lesson Plan  

 
 
 
 
 
 
 
 
 
 
 
 Page 2 of 5 
HMAC Robert Simpson 
27/11/2024 

Appendix 3 – FAA L3 Mental Health Session Plan 

Appendix 4 – PCDA Mental Health Lesson Plan  

Appendix 5 – PCSOA Mental Health Power point presentation. 

Existing Officer training 

We recognise that the need for ongoing and refresher training is essential in this complex 
area, and whilst it cannot be expected that officers make clinical judgements, we do 
require them to understand where updated information and support can be obtained in 
relation to clinical decisions and the powers and processes available to them.  

 has explained in his statement the existing training currently provided to 

assist.  

In addition, Response & Neighbourhood officers attend 5 Professional Development Days 
(PDD’s) throughout the year, during which mental health training can be included. These 
mandatory training days are allocated as part of their shift pattern to ensure attendance. 
Virtual sessions are recorded and it is expected that those unable to attend through 
sickness or leave to review the recordings.  

The content and subject matter of these PDD’s is flexible, allowing the time to be used 
based on priority and any potential learning gaps that have been identified. To this end, 
mental health awareness training has been included, with specialist inputs being provided 
by our Mental Health team and our wellbeing lead.  

Most recently, and going forwards, a detailed presentation has been included which 
covers poor mental health and the complexities faced by officers, serving as additional 
refresher training (appendix 6).  

Existing officers therefore receive training on mental health at least once a year, often 
more frequently, as the result of various ways in which inputs are delivered.  If they have 
been unable to attend any of the offered sessions, they are required to complete a 
national e-learning package, ‘Mental Health and the Police’ to ensure their knowledge 
remains current. 

Monitoring individual attendance and training  

We recognise that, when giving her evidence at Ryan’s inquest, the tutor officer was 
unable to recall specific training that had been provided to her and understand the 
concern and lack of confidence in our training provision that this resulted in for yourself 
and Ryan’s family.  

This officer was deeply affected by Ryan’s death and found providing in-person evidence 
distressing. Whilst we do not criticise that officer in any way, we believe this led to her 
vagueness and confusion.  

 
 
 
 
 
 
 
 Page 3 of 5 
HMAC Robert Simpson 
27/11/2024 

As a result, we identified that we were unable to confirm exactly what training this officer 
had personally received, whether she had missed sessions or whether her training was 
current. As this was the case for this officer, we are also concerned it may be for others.  
This is something that we are very keen to address going forwards to ensure all officers 
are attending training that they are required to complete.  

Historically, attendance at training is recorded locally, often by those delivering the 
training and there is reliance on supervisors to advise our training team who has and has 
not attended. This has made monitoring compliance and providing places to those who 
have missed training difficult.  

Going forwards, we are expanding the roll out of our LEARN platform, our new learning 
management system. Currently, all training attended by new recruits is recorded to 
ensure they complete necessary modules. This is now being expanded to record and 
capture all training to all officers, allowing us to review completion and missed courses 
more effectively.  

We expect to have current records entered and the system fully operation for all existing 
officers within the next 9-12 months. Our learning and development team, along with 
supervisors, will be able to access this system and ensure that required training for 
individual officers is both up to date and fully compliant. Where training has not been 
completed, places will be offered on the next course and the officer will be expected to 
watch the recorded session in a timely manner.  

Mental Health Services and joint training with the police 

You have raised concerns that under the new ‘Right Care, Right Person’ policy, the lack of 
joint training may lead to officers not understanding what information should be 
provided to ensure all relevant information is shared. 

We absolutely agree that police officers still need to understand and be trained in mental 
health matters to ensure they accurately assess situations when calls for service are 
received or attending those who may be in mental health crisis, despite the new way of 
working.  

To that end, our training provision, as outlined above and in our previous 
correspondence, will not diminish or be reduced.  

We have carefully considered whether joint training with SPFT could provide anything 
additional which could assist officers when referring matters and providing information to 
them, however we do not believe it is workable step and the cost and logistics of doing so 
would not be proportionate at this stage.  

 
 
 
 
 
 
 
 
 Page 4 of 5 
HMAC Robert Simpson 
27/11/2024 

However, following Ryan’s inquest, discussions have been held with our SPFT partners to 
see if any support can be provided to either organisation from the other in relation to 
training. These discussions are ongoing.  

Officers are currently required to contact the Blue Light Line (BLL) when dealing with an 
incident in which they believe mental health is a factor and will continue to do so with the 
introduction of the SPFT Rapid Response Service (RRS). 

The BLL provides clinical advice and guidance to police officers who are dealing with an 
incident. The sharing of information takes place by telephone, when on-scene. Officers 
speak to a clinician during this call and are expected to share information about the 
presenting situation in line with data protection legislation, the National Decision Making 
model and the College of Policing Mental Health Authorised Professional Practice.  

Officers will relay all information available to them, as well as the situation as it is 
presented with the aim of helping the clinician understand the totality of the 
circumstances. Officers will answer questions asked by the clinician to the best of their 
ability.  

Police Officers are not, nor can they be expected to be, mental health clinicians and are 
unable to perform clinical assessments on individuals. They are reliant on the clinicians on 
the BLL to give appropriate clinical guidance and complete clinical decision making. The 
Authorised Professional Practice on Mental Health states: ‘Police officers are neither 
trained nor equipped to carry out clinical assessments on the mental health or wellbeing 
of an individual (no matter how urgent the issue is) and it is not appropriate for them to 
fulfil the role of healthcare professional’.  

Officers are required to share all available permissible information about the presenting 
situation when utilising the blue light line. We recognise that officers may not know what 
is clinically relevant or not so are therefore encouraged to provide as much information 
as they can. The provision of detailed information allows the clinicians to receive the full 
picture of the incident as it is occurring and ask questions for further details on what they 
believe is relevant in the circumstances.  

We put out regular briefings on the importance of using the Blue Light Line (the most 
recent can be found at Appendix 7). 

Further, our SPFT partners are developing a Standard Operating Protocol for the RRS to 
provide guidance to officers who contact them for advice & assistance. This be shared 
with us once completed and will be communicated to all officers.  It will ensure officers 
are aware of the expectations placed upon them when contacting the BLL and how they 
can best support the clinicians with whom they are speaking.  

I hope the additional information provided herein reassures you that your concerns have 
been addressed.  

 
 
 
 
 
 
 
 Page 5 of 5 
HMAC Robert Simpson 
27/11/2024 

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  

Chief Constable