Inadequate communication between agencies
Sussex Police received 3 coroners' reports about this hazard between 28 May 2021 and 24 Sept 2024.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(5) Communication between the various teams and individuals were poor.”
Original on judiciary.uk ↗ Sussex Police responded.Response (PDF) ↗
- 3 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Lack of effective Communication between police officers The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as [the deceased] who was not known to the police.”
Original on judiciary.uk ↗ Repeated from the earlier report:Communicationbetween
Sussex Police responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“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.”
“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.”
2 more stated actions in the Promises tab.
- 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“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.”
Original on judiciary.uk ↗ Sussex Police responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Sussex Police
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2024Miles Hurley3 years 1 month after Kevin Fitton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight inadequate communication among personnel involved in the cases.
Kevin Fitton · 28 May 2021
“(4) There was a failure to understand how ABI impacted on Mr [name redacted] substance use and vice versa. (5) Communication between the various teams and individuals were poor. (6) Lead and Co-ordination were lacking.”
Original on judiciary.uk ↗ Miles Hurley · 9 Jul 2024
“Lack of effective Communication between police officers The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as [the deceased] who was not known to the police.”
Original on judiciary.uk ↗ 2021 → 2024Ryan Ouslem3 years 4 months after Kevin Fitton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in communication and information sharing among agencies involved in care. The earlier report cites poor communication between teams, while the later report stresses that organisations do not understand what information to share or what questions to ask.
Kevin Fitton · 28 May 2021
“(5) Communication between the various teams and individuals were poor.”
Original on judiciary.uk ↗ Ryan Ouslem · 24 Sept 2024
“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.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action
“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.”
Stated action
“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.”
Stated action
“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.”
Stated action
“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 [name redacted] necessary in this case.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Sussex Police at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2024 | 0.66 | 0.05 | Closely related · 0.90 | different |
| 2021 → 2024 | 0.67 | 0.04 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Sussex Police
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.