Recurring concern

Inadequate training and guidance for asphyxia risks during restraint

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First reported 2 Jul 2014•Latest report 15 Jan 2021

Definition

What this concern includes

Includes training, guidance, competence-assurance and related safety-information failures specifically concerning recognition or prevention of positional or restraint-related asphyxia across door-security, police, ambulance, healthcare, custodial and comparable restraint settings.

Not included

Excludes unsafe restraint techniques, monitoring or incident-response failures where no training or guidance deficiency is identified.
Excludes generic first-aid, clinical, security or restraint training that does not address asphyxia risks during restraint.
Excludes excited-delirium or acute-behavioural-disturbance training where the asserted deficiency does not concern asphyxia risks during restraint.
Excludes asphyxia risks unrelated to restraint, including general airway, choking or environmental asphyxia hazards.

Reports: 3
Individual concerns: 6
Date range: 2014–2021
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

College of Policing1

HM Prison and Probation Service1

Home Office1

National Police Chiefs’ Council1

NHS England1

North Wales Police1

Security Industry Authority1

Sussex Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

15 Jan2021
Staffordshire South
Concerns raised1
1. Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kevin John LOVATT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kevin John LOVATT was a serving prisoner at HMP Dovegate who died at the prison on 22 December 2017 after swallowing a package of illicit drugs and choking. The report identified concerns about communication, the response to choking, confusion at the scene, access to Advanced Life Support-trained staff and training on managing prisoners with items in their mouths that could compromise breathing.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths
Wider context from the report
“Following the investigation by the Prisons and Probation Ombudsman a recommendation was made that you should ensure that there is clear guidance and training on the safe use of force when resistant prisoners have items in their mouth which might compromise their breathing. In evidence at the inquest I heard that suitable training on this topic did not appear to have been delivered and that it would be appreciated by prison staff. I wonder therefore if the national training you provide could include control and restraint for prisoners with items in their mouths. ”
Source location
Kevin John LOVATT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Apr2019
West Sussex
Concerns raised1
1. Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Teach breathing monitoring through sound, touch, and observation of rib-cage movement, with annual refresher coverage.
  Stated by Sussex PoliceStated completed
Respondent positions 2
1. Position
  Updating the national restraint guidance and training products is the responsibility of the SDAR working group.
  Stated by College of PolicingRedirects responsibility
1. Position
  Individual police forces choose suitable tactical options and deliver them through local Personal Safety Training programmes.
  Stated by College of PolicingRedirects responsibility
AI-generated summary

Duncan Tomlin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present
Wider context from the report
“Importance of heightened risk of prone restraint when multiple factors affecting breathing are present 1. The current and earlier training plans, manuals and policies examined as part of the evidence in this inquest make clear references to risks associated with: (a) positional asphyxia; (b) handcuffs and limb restraints; (c) incapacitant spray; (d) acute behavioural disorder or symptoms thereof; (e) lack of oxygen due to physical exertion; (f) drug/alcohol intoxication; and (g) seizures. Although there is some cross-referencing between the various risk factors, the heightened risk to a person in prone restraint when a number of these factors are present is not emphasised or sufficiently emphasised. The multifactorial matters that can impact on a person’s ability to breathe and the heightened risks to a person in a position of prone restraint when experiencing such multiple factors are critical to the assessment of risk. ”
Source location
Duncan Tomlin · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Teach breathing monitoring through sound, touch, and observation of rib-cage movement, with annual refresher coverage.

Verbatim wording from the response
“Monitoring is covered across a number of Lessons such as ABD, Epilepsy, conscious and unconscious casualty and Positional Asphyxia. The information given on monitoring breathing in training includes more than noisy breathing – it also includes feel, touch and rise and fall of the rib cage. This is included in the lesson plans and is refreshed each year.”

Source location
2019-0135-Response-by-Sussex-Police
Page 2 · response
Published 14 June 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Updating the national restraint guidance and training products is the responsibility of the SDAR working group.

Verbatim wording from the response
“The College owns and publishes the NPSM in conjunction with the NPCC SDAR and the SDAR national practitioners’ working group. The SDAR are responsible for updating, developing and maintaining the NPSM and other national training products. SDAR membership includes physicians, self-defence and restraint trainers, academics, senior managers and experts (including from the Independent Office for Police Conduct, the Home Office, the Defence science and technology laboratory and the Police Federation amongst others). The College publishes the NPSM to the police service and then individual forces choose the tactical options contained within it that best meet the needs of their officers and staff in responding to local threats and deliver this through a local Personal Safety Training programme.”

Source location
2019-0135-Response-by-College-of-Policing
Page 3 · response
Published 14 June 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Individual police forces choose suitable tactical options and deliver them through local Personal Safety Training programmes.

Verbatim wording from the response
“The College owns and publishes the NPSM in conjunction with the NPCC SDAR and the SDAR national practitioners’ working group. The SDAR are responsible for updating, developing and maintaining the NPSM and other national training products. SDAR membership includes physicians, self-defence and restraint trainers, academics, senior managers and experts (including from the Independent Office for Police Conduct, the Home Office, the Defence science and technology laboratory and the Police Federation amongst others). The College publishes the NPSM to the police service and then individual forces choose the tactical options contained within it that best meet the needs of their officers and staff in responding to local threats and deliver this through a local Personal Safety Training programme.”

Source location
2019-0135-Response-by-College-of-Policing
Page 3 · response
Published 14 June 2019
Open published response
2 Jul2014
North West Wales
Concerns raised4
1. Lack of required training or knowledge on restraint and asphyxia dangers
2. Failure to audit accredited door-supervisor training on restraint and asphyxia
3. Failure to integrate asphyxia training into restraint training
1. Repeated coronial concern about door-supervisor training on restraint and asphyxia
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of required training or knowledge on restraint and asphyxia dangers
Wider context from the report
“(6) The SIA’s standards of conduct, training and levels of supervision issued pursuant to their statutory responsibilities under section 1(2)(e) of the 2001 Act, namely the “Specification for Learning and Qualifications for Door Supervisors” (Feb 2010) and the “Specifications for Learning and Qualifications for Physical Intervention Skills” (Aug 2010), do not include a requirement for training or knowledge on the dangers inherent in restraint, specific modes of restraint, positional asphyxia or traumatic asphyxia. ”
Source location
Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to audit accredited door-supervisor training on restraint and asphyxia
Wider context from the report
“(7) The SIA does not audit the training provided to door supervisors by accredited training providers, particularly on issues of restraint and asphyxia (traumatic and positional). ”
Source location
Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to integrate asphyxia training into restraint training
Wider context from the report
“(8) The mandatory training that door supervisors are required to undertake as a condition of the award of a licence by the SIA does not integrate training on asphyxia into the training on restraint (it is addressed by a limited and discrete element). ”
Source location
Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Repeated coronial concern about door-supervisor training on restraint and asphyxia
Wider context from the report
“(11) There have already been four ‘Rule 43’ reports to the SIA by Coroners concerning the training of door supervisors on restraint and asphyxia. ”
Source location
Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths

Concerns raised1

Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised4

Lack of required training or knowledge on restraint and asphyxia dangers

Failure to audit accredited door-supervisor training on restraint and asphyxia

Failure to integrate asphyxia training into restraint training

Repeated coronial concern about door-supervisor training on restraint and asphyxia

Actions described in response 1

Respondent positions 2