John Hurst

St Nicholas Hospital 

Jubilee Road 

Gosforth 

Newcastle upon Tyne 

NE3 3XT 

David Place  

HM Assistant Coroner for Sunderland 

Dear Sir 

Inquest into the death of John Paul Hurst 

Regulation 28 Report to Prevent Future Deaths Response 

Cumbria  Northumberland  Tyne  and  Wear  NHS  Foundation  Trust  would  like  to  express  our  deepest 

condolences  to  the  family  of  John  Hurst.  We  take  all  patient  deaths  very  seriously  and  investigate  them 

thoroughly to establish if lessons can be learned or services can be improved.  Your concern has made us 

reflect further on any additional learning and I will expand on it in the letter below. 

Your concern was as follows: 

'At  the  Inquest  I  heard  evidence  that,  following  John’s  arrest,  concerns  were  expressed  by  police 

officers  involved  in  the  investigation  as  to  his  mental  health,  and  by  John’s  sister  as  to  his  risk  of 

ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and 

Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release 

risk assessment, the custody sergeant had been greatly assisted by the information recorded on the 

electronic custody record regarding the concerns that led to the mental health assessment and the 

assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted 

that the electronic custody record contained limited information about the concerns of police officers 

and  John’s  sister, and  there  was a distinct lack of detail  about the  assessment itself and  very little 

analysis of the concerns and reasoning for the CJLD conclusion. 

I am concerned that the information on the electronic custody record was inadequate and lacked detail 

regarding the concerns for the detained person’s mental health, as identified by police officers and 

family, including the risk of suicide, the content of notes found and the detained persons history of 

suicidal ideation and previous engagement with mental health services. In addition, I am concerned 

that  the  record  also  lacked  a  detailed  analysis  of  those  concerns  by  CJLD  and  comprehensive 

reasoning for the assessment conclusion. 

 
 
 
 
 
 
 
 
 
 Deaths may be prevented if the recording of information in such cases is reviewed.'  

The Trust has carried out a thorough review of the guidance provided to staff in relation to entering information 

onto the electronic custody record and the following changes have been embedded: 

Local Operating Procedure 

The Criminal Justice Liaison and Diversion Team (CJLD) Local Operating Procedure has been updated and 

now  provides  clear  and  robust  guidance  to  staff  regarding  the  information  which  must  be  recorded  on  the 

electronic custody record following a screening assessment.  

The Local Operating Procedure requires staff to consider the following: 

- 

- 

If the Detained Person (DP) is known to CNTW services, how long they have been known and if they 

are open to a care team currently.  

If they are open to a care team, are they engaging and when were the last reviewed.  

-  Have they had any previous admissions to psychiatric hospital.  

-  Does the DP have a diagnosis.  

-  Are they prescribed any medication, and if so, are they compliant.  

- 

If the DP engaged in a screening.  

-  Mental state at time of screening. Please be explicit in evidencing why there is no evidence of a mental 

state deterioration or mental health crisis.  

-  Reference of your clinical decision making if you do not clinically share the concerns outlined in the 

referral.   

-  Risk to self, including any historical risks of suicide, self-harm and mental health deterioration.  

-  Risk to others, and risk from others.  

-  Any risk mitigations.  

-  Onward referral pathways, and there is no onward referral, why (i.e. did not want any support etc).  

- 

- 

- 

If they need an appropriate adult.  

If you have spoken with a carer, any concerns they may have.  

**Please document that you have verbally handed over to the custody sergeant and include their collar 

number.** 

-  What information you have placed with the DP’s property.  

-  That they can be referred back to CJLD if required.  

The above guidance is expected to be considered in addition to a verbal handover to the Custody Sergeant 

which already takes place. 

The updated Local Operating Procedure was circulated to staff on 12 November 2024 via email, please see 

"Exhibit A". Team training also took place on the 13 November 2024 to discuss the updated guidance. During 

2 

 
 
 
 
 
 
 
 
 the training discussion took place explaining the Regulation 28 and associated concerns. Advice was given 

with  regards  to  information  which  must  be  recorded  on  ECR  by  CJLD  practitioners  following  screening 

assessment, as outlined in Local Operating Procedure. Staff were instructed that verbal handover must always 

be  given  to  the  Custody  Sergeant  following  screening  assessment.    Collar  number  of  Custody  Sergeant 

receiving handover must be recorded on RiO and ECR.  Staff were given opportunity to ask questions, and 

confirmation was sought that changes to Local Operational Procedure were understood. 

Please see the updated Local Operating Procedure document at "Exhibit B". 

Clinical Audit Tool  

In  addition,  CJLD  Clinical  Leads  have  been  given  express  permission  by  the  Northumbria  Police 

(Superintendent responsible for Custody), to audit Trust staff entries into the electronic custody record provided 

the reason for accessing the record is documented. Clinical Audit of CJLD screening documentation is and will 

be carried out by CJLD Clinical Leads monthly for every staff member.  Three random samples are selected 

for each staff member each month. Audit includes records made on both ECR and RiO.  Audit outcomes are 

and will be discussed in monthly Clinical Supervision. 

Regular random  audits will  identify any issues with  staff  entries onto the electronic  custody  record and will 

ensure that changes are being embedded and improvements monitored.  

Please see the updated Clinical Audit of CJLD screening tool documentation at "Exhibit C".  

We hope that the above is helpful in addressing your concerns.  We are also  happy to  engage with you to 

discuss any issues or concerns generally, as we try to with all coroners in local areas.  Please let us know if 

that would be of any use. 

Yours faithfully  

Medical Director / Deputy Chief Executive 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 EXHIBIT A 

EXHIBIT A - Email to 
CJLD_Redacted.pdf  

EXHIBIT B 

EXHIBIT B - CNTW 

LD  MHTR Processes Nov 24.pdf

EXHIBIT C 

EXHIBIT C - Clinical 
Audit Tool 2024_Redacted.pdf

4

Your Ref: 

Criminal Justice and Custody Department 
Newcastle City Centre Police Station 
Forth Banks 
Newcastle upon Tyne 
NE1 3PH 

Email: 

Mr David Place 

HM Assistant Coroner for the City of Sunderland 

BY EMAIL ONLY: 

6th December 2024 

Dear Mr Place, 

Inquest touching upon the death of Mr John Hurst 

I  write  further  to  the  inquest  in  this  matter  which  concluded  on  11  October  2024,  and  to  your 

Regulation 28 report dated 23 October 2024. 

I note the concerns expressed in your report that the custody record contained limited information in 

relation to concerns for John’s mental health made by the investigation team and John’s sister.   

I agree that it is important that custody officers record all relevant information and concerns expressed 

in relation to the mental health of a detainee.  This is something which all custody officers should be 

aware of.  In order to ensure that custody staff are aware of their obligations in this respect, following 

receipt  of  your  report  appropriate  instruction  and  learning  from  this  Inquest  has  been  provided  to 

custody staff via: 

1.  The Force Custody Newsletter; 

2.  The Force ‘Custody Compendium’ (easy access guidance for custody staff); 

3.  A reminder being shared directly with all departmental Custody Sergeants. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 2 

I hope the above action meets with your approval. 

Yours sincerely  

Chief Inspector 

Force Custody Manager 
Criminal Justice and Custody