“(brief summary of matters of concern) During the course of the Inquest, evidence was…”
Dated 20 Jan 2025, from the coroner for West Sussex, Brighton and Hove. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 17 Mar 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated20 Jan 2025
- Deadline17 Mar 2025
- Published on judiciary.uk20 Jan 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sussex Partnership NHS Foundation TrustNamed in the report as “Sussex Partnership Foundation Trust” | Response publishedPublished on judiciary.uk in January 2025. |
The coroner’s concerns
(brief summary of matters of concern) During the course of the Inquest, evidence was provided of the many services available to young men such as Harry who have attempted suicide including services such as the Haven and numbers they can contact if they are suicidal. However, I am concerned that this information is not in fact provided to people in Harry’s circumstances. Evidence was heard from Harry’s father that indicated that in fact the contact numbers are not answered and do not cater for those with hearing difficulties or other disabilities. Young people in particular are not aware of other services such as Papyrus, a charity that has a round the clock suicide prevention helpline aimed at young people who are suicidal. Younger people with mental health difficulties of course will tend to be more familiar with social media and apps to discuss their problems in addition to just conventional phone numbers. I am also alarmed at the evidence given at the Inquest that cutbacks and funding issues may result in services to those with mental health difficulties being reduced even further. The Health Secretary will be copied into this Report because I am concerned this may well be a national problem. The inability of young people in particular with mental health difficulties (and their families) Regulation 28 – After Inquest Document Template Updated 30/07/2021 to contact someone at all times who will be able to speak with them (or being made aware that there are agencies who can speak with them) does give rise to a risk of future deaths and action should be taken by the Trust to resolve this.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0034
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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