East Sussex
Coroner Area
Reports: 32
Earliest: Jan 2014
Latest: 27 Feb 2026
97% response rate (above 63% average).
Reece Lapina-Amarelle
All Responded
2019-0274
9 Aug 2019
Department of Health and Social Care
NHS England
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The report identifies a lack of resources and treatment for individuals with serious mental illness and substance misuse issues, as well as insufficient information sharing between mental health services and substance misuse services.
Noted
(AI summary)
The Department of Health and Social Care acknowledges the concerns and notes the NHS England and Improvement response. They commissioned a review of the Mental Health Act and will publish a White Paper setting out the Government's response. NHS England expresses condolences and acknowledges the concerns raised, referencing existing initiatives to improve mental health services and digital tools. It notes that the Department of Health and Social Care is developing a response to the Independent Review of the Mental Health Act, and that the government has committed to publishing a White Paper.
Ryan Trimmer
Partially Responded
2019-0215
21 Jun 2019
HMP Lewes
HM Prison and Probation Service
State Custody related deaths
Concerns summary (AI summary)
The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.
Action Planned
(AI summary)
HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to staff as part of the prison’s monthly training provision.
Dean Barrell
All Responded
11 Oct 2018
Prison and Probation Service
State Custody related deaths
Concerns summary (AI summary)
A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, highlighting unacceptable communication delays for vulnerable individuals.
1 response
from Dean BARRELL
Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi
All Responded
2023-0105Deceased
24 Jul 2017
Birnberg Peirce Solicitors
Department for Transport
Health and Safety Executive
+7 more
Other related deaths
Concerns summary (AI summary)
There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.
Noted
(AI summary)
The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches, and states that it can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. The council acknowledges the concerns and refers to previous reports and statements regarding beach management at Camber Sands, and states that restricting public use of beaches would be disproportionate. The Forum intends to update and expand the use of the WAID database and is seeking to identify suitable sources of funding for this development work. RoSPA states that it seeks to influence, inform, coordinate activity and advise within the existing structures for water safety, and states that significant landowners successfully manage sites with significant hazards to the public without noticeable impacts or blanket restrictions. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions, and will conduct an independent review of its accident prevention activity.
Sabrina Walsh
All Responded
2017-0449
14 Jul 2017
Department of Health and Social Care
Sussex Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.
Noted
(AI summary)
NHS England provides context regarding the use of CCTV in mental health units, referencing relevant guidance and the Sussex Partnership NHS Foundation Trust's consultation with patients and staff. They note the Trust's agreement to install CCTV in entrance areas. The Trust is implementing the installation of CCTV in the entrance areas of all 12 of its acute inpatient/PICU wards, including Woodlands.
Amy El-Keria
All Responded
2016-0347
3 Oct 2016
Department of Health and Social Care
Hounslow Borough Council
Child Death (from 2015)
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.
Action Planned
(AI summary)
NHS England and Health Education England are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. NHS England commissioned the Royal College of Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to develop guidance on staffing. NHS England and Health Education England (HEE) are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. The Royal College of Psychiatrists and NCCMH were commissioned in 2016 to develop guidance on staffing for inpatient and community mental health care for children, young people and adults. The London Borough of Hounslow has updated its Thresholds Guidance & Assessment Protocols, with specific reference to children in need under S17 of the Children Act 1989 for those in hospital or other settings. Staff will receive briefings to reinforce awareness of their duties and the importance of family contact. Priory Group has enhanced observation recording forms and clarified its policy on information sharing. Monthly simulation drills are undertaken for BLS and ILS. A new tool for better assessment of behavioural risk prior to admission is being introduced with staff briefings underway. Priory Group has enhanced observation recording forms and clarified its policy on information sharing. Monthly simulation drills are undertaken for BLS and ILS. A new tool for better assessment of behavioural risk prior to admission is being introduced with staff briefings underway.
Mustafa Cicek
Partially Responded
2014-0116
13 Jan 2014
Department for Transport
National Highways
The Chief Coroner
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on the carriageway approach.
Action Taken
(AI summary)
The Highways Agency has installed 'SLOW' road markings and removed a eucalyptus tree. It is also increasing the number of chevrons on the bend and ensuring they are on yellow backgrounds.