A man took his own life three days after police and firefighters forced entry into his flat due to concerns for his welfare.

Ryan Ouslem, from Worthing, died of carbon monoxide poisoning on August 1, 2022.

Police and firefighters found him dead on his bed in his flat.

Three days before, on July 29, police and firefighters had gone to the 34-year-old's flat and forced entry, a prevention of future deaths (PFD) report has now revealed.

He had put a post on Facebook which made people concerned for his welfare.

At that time, he denied any ongoing intent to harm himself. Police offered Ryan a call from a mental health nurse the following day and left the scene.

Ryan Ouslem's bandmates said he was 'an exceptionally talented and lovely guy'Ryan Ouslem's bandmates said he was 'an exceptionally talented and lovely guy' (Image: Liquid Logic)

After the inquest into his death concluded last month, Robert Simpson, assistant coroner for West Sussex, Brighton and Hove, raised concerns about the mental health training police receive in the PFD report.

The inquest heard the police constable who went to Ryan’s flat on July 29, 2022, had had some suicide awareness training when she began her role as a police officer seven years prior, but “could not remember it”, Mr Simpson wrote.

Mr Simpson said the police officer’s evidence showed that she “did not fully understand when police powers under section 136 of the Mental Health Act 1983 can be exercised”.

The officer was a coach for newly qualified officers, the inquest heard.

Mr Simpson said she “did not make enquiries at the scene that might have been expected, for example, reading the Facebook message in question, asking questions about why the flat was not safe to enter and seeking information from Ryan’s mother who was present at the time”.

The coroner said he “still has concerns” after Sussex Police provided information about their mental health training after the inquest.

“The police have stated that mental health training has been a particular focus for some time,” Mr Simpson said.

“Despite this an officer with a training role was unable to explain what training that was and when they had received it.”

Mr Simpson also raised concerns about how mental health services and the police work together.

A street triage practitioner from Sussex Partnership Foundation Trust (SPFT) had been with police on July 29 when they went to Ryan’s flat, the inquest heard.

READ MORE: Man, 23, ­died after intentionally driving towards lorry on dual carriageway

“In this case not all relevant information was passed to the mental health practitioner in a timely manner,” Mr Simpson said.

“An SPFT witness stated that it was not for them to provide training to the police and that
she had not been on any cross-service training.”

The coroner said he was informed of a new system in the police where mental health workers are no longer embedded with officers.

“I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide.”

Ryan Ouslem was found dead in his flat. He had battled with mental ill healthRyan Ouslem was found dead in his flat. He had battled with mental ill health (Image: Liquid Logic)

The coroner said there does not appear to have been any joint training and he has not been made aware of any being planned.

“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,” Mr Simpson said.

Ryan loved music and played guitar in a band called Liquid Logic.

His bandmates told The Argus: "Ryan was an exceptionally talented and lovely guy who had battled an awful illness for many years.

"Lockdown had a huge impact on his mental health suppressing his ability to reset mentally through his love of playing music and the gym."

Liquid Logic added: "Sadly he was ultimately let down by numerous failings, not only by the system but also the people supposedly trained and in a position to source the necessary care and help he needed.

"This is an incident that could so easily have been prevented, he was genuinely adored by all that knew him, loved him and listened to his unbelievable talent encompassing emotions with a guitar. Unfortunately words, apologies or reports aren't enough to bring our friend back, he was failed by people who should have known better."

Sussex Police and Sussex Partnership NHS Foundation Trust have now offered their condolences to Ryan's loved ones.

A spokesman for Sussex Police said: "Police were called to check on Ryan’s welfare on the afternoon of July 29, 2022. Officers engaged with Ryan for a period of time and ensured his well-being before leaving him with an adult at the property and submitting the relevant and appropriate reports to partner agencies. Ryan sadly passed away on August 1, 2022.

"We recognise the complex challenges faced by our officers when dealing with those in mental health crisis, and training is in place to ensure that officers are aware of the powers they have in such circumstances. We continue to work closely with our healthcare partners to ensure medical professionals are consulted and the most appropriate care is provided.

"We acknowledge the inquest conclusion and thank the coroner and the jury for the time taken to properly scrutinise the circumstances surrounding Ryan’s death. As a force, we are committed to continuous learning and we are carefully reviewing the Prevention of Future Deaths report issued by the coroner to ensure where changes or improvements are identified, they are implemented."

A spokesperson from Sussex Partnership NHS Foundation Trust said: "We are reviewing the Prevention of Future Deaths report and will be responding formally to the points raised by the coroner.

"To ensure that people in Sussex get the right help at the right time with their mental health, we have been working with the emergency services, staff and people who use our services to develop a new mental health 'rapid response' service in Sussex.

"The new 'rapid response' service, which is due to be launched by the end of this year, will offer 24/7 advice and guidance to the emergency services and on-scene support to people in mental distress.

The Samaritans charity advises that whatever you are going through, you don’t have to face it alone. Call Samaritans for free on 116 123, email jo@samaritans.org or visit www.samaritans.org for more information.