Jade Hutchings

PFD Report All Responded Ref: 2022-0398
Date of Report 28 October 2022
Coroner Penelope Schofield
Coroner Area West Sussex
Response Deadline ✓ from report 4 January 2023
All 3 responses received · Deadline: 4 Jan 2023
Coroner's Concerns (AI summary)
Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.
View full coroner's concerns
During the investigation, 1. Inadequate Police training on Mental Health

During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training. Some officers could not recall any additional training provided since their initial training when they first joined the force.

The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full.

The expert police witness, , told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient. None of the officers involved in this case had yet undertaken this online training.

It was his opinion that officers should be provided with the nationally recognised two day training course written by the College of Policing, The course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police.

There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide.

2. REBOOT - Lack of provision to for older age group

There was clear evidence that Jade was vulnerable and had become involved in violence and crime in 2019 (the year before his death). It was believed by some that Jade exploited by gangs running county line drug operations. A need for an early intervention was identified by his social worker and a referral to Reboot was made.

The Inquest was told that at the time REBOOT was prioritising 12 – 14 years children and as Jade was nearing 18 they were unable to work with him. This was a missed opportunity for Jade to be involved in a form of early intervention before his life started unravelling and he became more heavily entrenched in the world of crime. It is understood that at the time of Jade’s death the Police and Crime Commissioner was responsible for the REBOOT scheme but at the time of writing this report the scheme is now run by Sussex Police.
Responses
Police and Crime Commissioner
8 Dec 2022
Action Taken
The Police and Crime Commissioner launched the REBOOT initiative in 2019 as an early intervention youth programme, secured additional funding for it, and funded it for an additional year in 2020/21. In April 2021, coordination of the REBOOT scheme was migrated to Sussex Police and funded from the force’s core budget. (AI summary)
View full response
Dear Ms Schofield Further to your letter dated 31 October concerning the Regulation 28 Report to Prevent Future Deaths and your requirement for me to respond to comments in your report about the REBOOT initiative, I can report as follows: I named and launched the REBOOT initiative in 2019, as an early intervention youth programme and local response to the Government’s Serious Violence Strategy. To do this, I secured one-off funding of £890,616 from the Home Office’s Early Intervention Youth Fund to increase support for young people in Sussex who were at risk of becoming involved in serious violence. This additional funding was over and above the annual policing budget for Sussex and complimentary to the wider Sussex statutory services provided to young people delivered by local authorities and their youth justice and social services. REBOOT was co-designed with local statutory and non-statutory partners and was aimed at complementing existing services provided by statutory agencies to identify young people showing signs of taking part in risky behaviours and on the periphery of becoming involved in serious violence. REBOOT was not intended as an alternative criminal justice pathway where a young person was already part of Youth Justice Service case load. It was acknowledged by all agencies at the outset that the additional funds, albeit significant, would be unlikely to satisfy the total demand across Sussex and, hence, only those young people displaying the greatest risk would take priority. Initially it was anticipated this funding would provide services for around 300 young people. In order to prioritise and to have the most impact, young people are referred into REBOOT when starting to display the early signs of being at risk of becoming involved in crime and violence. These include but are not limited to: non- engagement with school; missing episodes; being part of a peer group coming to the attention of police; harmful risk taking; alcohol or drug use; and aggressive or impulsive behaviour. The programme engages positively with a small cohort of those aged between 10-17 years of age, at risk of committing serious violence, and those who have already come to the attention of the police through anti-social behaviour and low-level criminality. It is a strength-based programme which builds on the positive and protective factors in a young person’s life. The funding enabled REBOOT to be implemented and provided a range of extra resources to manage a target of 300 young people. The triaging process was conducted by dedicated REBOOT coordinators, supported by a dedicated REBOOT Sergeant embedded in Sussex Police structures. This involved looking into the young person’s police history and understanding their involvement with the police to date. Often this included family history and past school incidents. Co-ordinators reviewed specific incidents further, to understand the young person’s involvement and decipher whether they met the risky behaviours criteria for early intervention. If the young person’s history was limited, and the recent incident met the criteria,

the Co-ordinators would conduct a Multi-Agency Safeguarding Hub (MASH) check to understand their involvement with social services. If they were not open to social services, then this would be a successful candidate and they could be enrolled on the REBOOT programme.

The Home Office grant provided opportunities to test this initiative alongside constraints in terms of the volume of young people it could impact upon, as not every young person who comes to the attention of police can be referred onto the REBOOT programme.

Following on from the initial success of REBOOT, I funded the programme for an additional year in 2020/21 at a cost of £734,532 from my budget. During this period, the positive outcomes were verified and, in April 2021, co-ordination of the REBOOT scheme was migrated across to Sussex Police to become part of the embedded targeted response for the needs of young people in Sussex and funded from the force’s core budget.

In terms of further action, in my role as the Sussex Police & Crime Commissioner, I have a statutory duty to hold the Chief Constable to account for policing in its totality and, at my monthly webcast Performance Accountability Meetings (PAM) I regularly scrutinise the Chief Constable over how Sussex Police responds to the risks of young people becoming involved in serious violence and will continue to do so. This scrutiny includes how REBOOT continues to play a part in such matters. The last time I enquired into REBOOT at a PAM was on 18th March 2022, the meeting and minutes can be viewed on the following link: SPCC - Watch Live (sussex-pcc.gov.uk)
Sussex Police 20.12 Police / Law Enforcement
20 Dec 2022
Action Taken
Sussex Police has completed a roll out of a more modern BWV platform, allowing officers to swap out cameras with low battery life, and run a weekly “bad battery” report to determine cameras that may have battery issues. (AI summary)
View full response
Dear Penelope, Thank you for your letter dated 26th November relating to the inquest into the death of Jade Hutchings. The Regulation 28 report issued to me on 31st October is progressing, and we intend to have a full reply submitted to you as soon as we are able. You highlighted a further issue in respect of body worn video (BWV) cameras and their batteries. I have made enquiries about this matter and am keen to provide you with a response to those points. Since the sad death of Ms Hutchings Sussex Police has completed a roll out of a more modern BWV platform, as well as refreshing policy on BWV usage by officers and staff. This new system allows colleagues to swap out a camera with low battery life for a new one with a fully charged battery within seconds, this is very different from the previous system which were personal issue cameras which relied upon officers and staff charging their own cameras. This system allows officers to have the best available camera in terms of battery life. The new cameras also have an audible low battery alert giving officers notice that they will be required to swap their current camera for a new one as soon as possible. Additionally our BWV managing team run a weekly “bad battery” report to determine cameras that may have battery issue to allow them to removed from service and a fix to be made. This feeds into the contract that we have with the supplier to ensure that new batteries are covered under the warranty ensuring they are fixed in a timely way. Finally our new style of BWV camera are constantly recording as when an officer or staff member activate the camera is begins the recording 15 seconds prior to the officer pressing the record button. Therefore I am confident that this new platform now means that officers and staff have no cause to not turn their cameras on to preserve battery life, which will prevent any issues such as the one you raised being a concern in the future. I am grateful to you for raising this issue, and hope that this reassurance is sufficient.
Sussex Police 21.12 Police / Law Enforcement
21 Dec 2022
Action Taken
Sussex Police has significantly developed mental health training for officers since 2020, enhancing both entry-level and continued professional development; a retrospective review found the deceased's needs likely surpassed the criteria for the REBOOT programme at the time of referral. (AI summary)
View full response
Dear Ms Schofield, Sussex Police Response to Regulation 28 - Issues arising from the death of Jade Hutchings Thank you for including us within the scope of this notice. I welcome it, as it is vital that Sussex Police, and indeed all public authorities, learn from such tragic incidents as this and strive to improve where appropriate. I will deal with your concerns sequentially: Inadequate Police training on Mental Health
1.1 - ‘During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training. Some officers could not recall any additional training provided since their initial training when they first joined the force’. Response Sussex Police recognise that at the time of Jade’s death in May 2020, the provision of Mental Health training for Police Officers and staff was limited to their initial training. The level of training has been significantly developed in the intervening two years and has been enhanced both at entry level and through continued professional development. The contents of both syllabuses are detailed below. Current Training Delivered to Officers Upon Joining Sussex Police Mental health training is provided to all Student Officers in Sussex during their initial training programme. In December 2020 the initial training package was enhanced and again updated in March 2022. The training being delivered to all new officers joining Sussex Police at the time of writing (December 2022) is set out below. Face-to-Face input on Mental Health Awareness and Powers covers topics including:
• What is mental health
• Stigma around mental health
• Mental health statistics
• Learning Disabilities

• Autism
• Section 136 Mental Health Act 1983
• Section 135 Mental Health Act 1983
• Mental Capacity Act 2005 In addition to this, there is an online ‘Vulnerability’ section within the programme, which requires Student Officers to read about the Mental Health Act, Mental Health Codes of Practice and the Mental Capacity Act. They look at how mental ill health can make someone vulnerable and are required to research partner organisations that support people with poor mental health. The update in March 2022 brought the addition of:
• Including mental health under disabilities when discussing the Equality Act 2010. The Equality Act links to neurodiversity but not specifically mental health.
• Effects of societal, cultural, and personal (e.g., ethnicity and mental health) influences and the conflict such influences can cause (this is specifically under conflict management).
1.2 The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full. The Sussex Police Mental Health Guide was been relaunched on the Sussex Police internal website which is available to all staff. It has also been added to apps which are available on mobile devices provided to all frontline staff. Resources designed to be easily accessible to support officers at the point of need and provide a quick and readily available reference point include the “Crewmate” and “Quick links” apps, which are both available to officers and staff on their Mobile Data Terminals (MDT) this makes the information accessible whilst attending incidents. Some of the resources available on ‘’Crewmate’ are:
• Suicide Intervention
• Mental Health Guide Sussex, and an additional 1-page guidance document that instructs officers how to manage s136 detentions
• S136 MHA A&E Response Guide
• Full Mental Health Guide
• Safeguarding Guide

1.3 The expert police witness, Michael Brown, told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient. None of the officers involved in this case had yet undertaken this online training. It was his opinion that officers should be provided with the nationally recognised two-day training course written by the College of Policing, the course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police. Response The comments and concerns of the Expert Police Witness, Michael Brown in relation to Sussex officers undertaking the College of Policing (CoP) two-day training course, have been carefully considered. The College of Policing do not deliver a two-day classroom-based learning course but do offer a ‘Mental Health Programme’ (published in October 2021) intended to support the Police Service to develop and deliver their own ‘in house’ training programme. The College of Policing recommend a ‘target audience’ for each module of their Mental Health Programme and individual forces are given discretion as to who would be more appropriate to attend specific parts of the programme; for example, the target audience for developing a strategic response to mental health is aimed at Inspectors and above up to and including NPCC and police staff equivalent. Two, specific elements of the programme are targeted at First Responders:
1. The College of Policing e-learning module. – Mental Health and the Police This module has already been included in our CPD programme and all response officers must have completed this as part of the CPD schedule in 2022.
2. E-Learning Mental Health Legislation / Providing a response to Mental Health Incidents (Classroom based) / Responding to Suicide In 2021, the Sussex Police internal ‘e-learning’ package included all of these elements. With the implementation of the additional training courses detailed above, our mental health training provision for officers and frontline staff has improved significantly since Jade’s tragic death in May 2020. We also continually look to identify any improvements that can be made to support our officers and staff in dealing with mental health incidents. It is important to note that Police Officers are not Mental Health Practitioners, and it is not their police role to have an in-depth knowledge of all mental health conditions and circumstances. Whilst the policing responsibility should predominantly be the prevention and detection of crime, it is highly likely that Police officers and Police staff will encounter people who are vulnerable due to mental health. This could be in a criminal justice capacity such as a victim, witness or suspect of a crime and also in a health care capacity when exercising police powers to support health care agencies. It is of course incumbent that Police Officers are aware of their powers under s136 and s135 of the Mental Health Act (1983); Mental Health Codes of Practice and the Mental Capacity Act (2005), and this is incorporated into existing training.

Continued Professional Development (CPD) – Mandatory Programme This is a mandated programme for Sussex Police response teams, with time for completion embedded into the officer’s shift pattern. The training is a mixture of virtual webinars and e-learning courses. It is the individual’s responsibility to ensure that they catch up on anything they miss due to absence, and provision is made for them to do this via self-directed study slots, written into the CPD scheduling. It is an expectation via management that all officers complete these sessions and the content provided. In addition, wherever possible these sessions are recorded, and the content uploaded onto ‘College Learn’ for out of hours availability. The following training has already been delivered as part of this mandated programme: Mental Health Awareness – Sussex (e-learning) – January/February 2022 This course reviews the understanding of mental health and the powers and responsibilities that Sussex Police have to those suffering from a mental health condition. The course provides key contacts, legislation, procedural guidance, and referral information for further awareness. The course also includes information regarding resources available to officers on their personal issue MDTs (Mobile Data Terminals) such as Mental Health Forms, Refence materials, resources, and internal support. Mental Health and the Police Programme – College of Policing (e-learning) –October/November 2022 This is the College of Policing e-learning package on ‘College Learn’. This programme provides a general awareness of mental health conditions and diversity. The content consists of two modules: Mental Health Explained
• Including: defining mental health, poor mental health, core issues, mental health conditions and vulnerability, learning disabilities, misconceptions, legislation, assessing capacity

Mental Health Initial Response
• Including: communication - verbal and non-verbal, point of view communication, point of view de-escalation, MHA Section 135 (1) warrants, criminal suspect with poor mental health, vulnerable victims and witnesses, vulnerable suspects, other causes for incidents and safe and well checks. Personal Safety Training Personal Safety Training is mandatory safety training which all officers are required to attend twice a year. The training includes a number of real-life scenarios which officers will encounter when responding to incidents. The training content during October 2021 – March 2022 included an input

on mental health crisis and distressed victims, highlighting some of signs and symptoms that a person in a mental health crisis may display, and reinforces the options available to officers in responding to such incidents. It also reminds officers of their powers, and what they need to consider under the Mental Health Act. The scenarios complement the other mandatory mental health training provided by Sussex Police.

Current courses now include a mental health training input on the following mandatory courses:
• Initial Inspector Training: A minimum of an hour session to go over some of the key areas of mental health and policing that may require Inspector oversight. Features discussion on s136 pathway and escalation.
• Custody Officer Training: A session for Custody Officers to support them in managing some of the complex areas of interface between mental health and the criminal justice system. This features discussion on s136 detentions from Police custody.
• Call Handlers Mental Health Training: A half-day session on the variety of mental health related calls that they may encounter. This includes an input on s136 detentions, and the training will be delivered to all Control Room Operators before the end of 2022. All training that is delivered by Sussex Police on Mental Health & Policing is in line with the College of Policing’s APP on Mental Health & Policing and is currently developed and delivered with oversight from a mental health social worker.
1.4 There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide. We understand this observation to relate to the wider context of the ‘Blue Light Line’ (of which the Haven at Millview forms part), the telephone provision provided by Sussex Partnership NHS Foundation Trust for officers to use for consultation about mental health incidents, namely when they are considering using their powers under s136 of the Mental Health Act (1983). In response to requests from frontline Police Officers to have additional information in relation to s136, an additional guide to s136 detentions was published in January 2022 which clearly outlines the role of ‘The Blue Light Line’. This document was reviewed and developed into a short 2-page document that has been added to the ‘Crewmate’ app. Sussex Police also publish its ‘Mental Health Guide’ on the Crewmate app for officers to refer to.
1. REBOOT - Lack of provision for Older Age Group There was clear evidence that Jade was vulnerable and had become involved in violence and crime in 2019 (the year before his death). It was believed by some that Jade exploited by gangs running county line drug operations. A need for an early intervention was identified by his social worker and a referral to Reboot was made.

The Inquest was told that at the time REBOOT was prioritising 12 – 14 years children and as Jade was nearing 18 they were unable to work with him. This was a missed opportunity for Jade to be involved in a form of early intervention before his life started unravelling and he became more heavily entrenched in the world of crime. It is understood that at the time of Jade’s death the Police and Crime Commissioner was responsible for the REBOOT scheme but at the time of writing this report the scheme is now run by Sussex Police. Response The Reboot programme was introduced in June 2019, originally financed by Home Office funding and later financed, and overseen by the Office of the Police and Crime Commissioner (OPCC), with officers from Sussex Police working on the programme in tactical roles. The age criteria set by OPCC made the programme available to children aged between 10yrs – 17rs. From April 2021 the Reboot programme continued to be available, but funding and oversight was taken over by Sussex Police. The age criteria remained at 10yrs – 17yrs but without any focus on a particular age group within that range. Reboot is intended to be an early intervention, specifically targeted to a child who is at Level 2 of the Continuum of Need, and has the following indicators:
• Exposed to criminal behaviour as the norm.
• High disregard for the rules.
• Aggressive behaviours
• Experience of violence within the community.
• High Impulsivity
• Engaging in harmful risk taking.
• Early Signs of difficult relationship with caregiver/family member.
• Engaging in unhealthy and potentially exploitative relationships.
• Alcohol or Drug use.
• Not engaging positively at school. Children at level 3 & 4 of the Continuum of Need remain the responsibility of statutory services, as their needs are considered too high for the Reboot programme. In light of the Reboot Programme in 2019 being staffed by officers from Sussex Police, to assist our response to the Regulation 28 Report a retrospective review has been carried out to ascertain whether, at the point of referral Jade could have been accepted onto the programme.

Whilst Reboot accepted children up to the age of 17, they needed to have sufficient time to work with the children before their 18th birthday (including a 12-week mentoring programme). As the programme started in June 2019, the referral window for Jade would have been approximately 3 months (June to August) due to his age. Although we are unable to confirm exactly why Jade was not accepted on to the Reboot programme, it is unlikely that it was based on his age alone, as at the time of the referral Jade’s needs were too high and had surpassed the Reboot criteria. We have worked hard to ensure that we are able to provide a comprehensive and constructive response which we hope addresses the issues raised within the Regulation 28. However, if there are any follow-up questions about this response, please do come back to me and I will do my best to resolve them.
Sent To
  • Sussex Police
  • Sussex Police and Crime Commissioner
Response Status
Linked responses 3 of 2
56-Day Deadline 4 Jan 2023
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 24th May 2020 I commenced an investigation into the death of Jade Hutchings aged 18. The investigation concluded at the end of the inquest on 28th September 2022. I concluded with a narrative conclusion of:- Jade, who was vulnerable, had been struggling with his mental health. He had been using alcohol and drugs to mask underlying issues and he had been finding it difficult to engage with services in order to address this. There were missed opportunities by a number of services to proactively engage with Jade to ensure that he was being encouraged to address his dependency on alcohol and drugs and notably the missed opportunity to carry out a child in need review when Jade was approaching 18 which did not occur due to his case being closed prematurely. Jade’s death was contributed to by neglect.
Circumstances of the Death
In 2019 Jade’s behaviour started to deteriorate. He dropped out of St Pauls’ College and started to get involved in criminal activity. He came to the attention of Children Services, the Mental Health Service and the Police (having been the victim of assaults, being involved in domestic disputes and having been arrested for aggravated burglary). Alcohol and substance misuse played a substantive part in his lifestyle. At 22:07 on 20 May 2020 Mrs Hutchings (Jade’s mother) reported to the police that Jade (who was 18 at the time) had not returned home. She said that he had left the house at 17:00 under the influence of alcohol and drugs saying that he would be back soon. He didn’t return so Mrs Hutchings contacted his friends but they had not heard from him. She was concerned for her son as this was out of character for him and he had previously been assaulted.

The Police treated Jade as a missing person and tried to locate Jade. At 03:00 police located Jade at Hastings Town Centre. He was drunk. The Police did not detain him under Section 136 Mental Health Act as they did think it was necessary. They transported him back home to Haywards Heath. On arriving home he went to bed. When Jade woke up the following morning, he was argumentative with his mother. He eventually calmed down and apologised. Later that morning his mother and sister left the house to go to the shops. They arrived back home at about 14:00 and went upstairs where they found Jade hanging

Mrs Hutchings and some of her neighbours began CPR on Jade and an ambulance arrived along with several police officers who assisted with CPR. Jade was taken to Brighton Hospital where despite treatment he died on 23rd May 2020.

The Cause of death is recorded as: - 1a Hypoxic Brain Injury 1b Asphyxia due to Hanging by Hanging 21/5/20
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.