7 Oct 2025 Ann Sabrina LASKOWSKY · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Lack of clear training on assessing whether a person is breathing normally View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
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AI-generated summary
Ann Sabrina LASKOWSKY · 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
Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear training on assessing whether a person is breathing normally
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed ; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned.
” Source location Ann Sabrina LASKOWSKY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed casualty assessment, primary survey, breathing checks and acute alcohol intoxication recognition in initial and annual refresher first-aid training.
Verbatim wording from the response “In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Regulation 28 reports and relevant inquest findings as standing agenda items of the NPCC First Aid Forum.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and circulate national learning summaries and practice notes to all police forces.
Verbatim wording from the response “To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:” Source location Response from College of Policing
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How this respondent action was interpreted
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PFD Monitor interpretation Engage force training leads and clinical governance advisers to support local implementation of national learning.
Verbatim wording from the response “To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised First Aid Learning Programme content mandating assessment of breathing and responsiveness in Learning Outcome 1.3.
Verbatim wording from the response “Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add clarification of normal breathing rates, visible breathing effort and distress to first aid training.
Verbatim wording from the response “To assess your concerns about the assessment of whether a person is breathing normally, the Trainers will now include a discussion and clarification and confirmation of 12-20 breaths per minute (they should be taking a minimum of 2 breaths in 10 seconds). If it appears as though they are in distress or it is taking visible effort to breath, this is not normal breathing.” Source location Response from West Yorkshire Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Practise breathing assessment using acting casualties in face-up, face-down and seated positions.
Verbatim wording from the response “The above will be put into practice by using acting casualties who are found in a variety of positions such as face up on the floor, face down on the floor and, also in a sitting position.” Source location Response from West Yorkshire Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual forces are responsible for delivering FALP training in accordance with their local clinical governance arrangements.
Verbatim wording from the response “In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nationally standardised teaching methods are not mandated; each force’s clinical governance group determines them with consultant-level medical input.
Verbatim wording from the response “Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.” Source location Response from National Police Chief's Council
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1 Aug 2025 Brian Thomas RINGROSE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 2
Failure to check airways and breathing rate during restraint View source Failure to listen to, interpret and respond to breathing during restraint View source
This report raised 20 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Review and publish mobile Snap Guides covering safety-officer duties, welfare monitoring, restraint, spit guards, acute behavioural disturbance and prone ground-pin risks.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Introduce positional-asphyxia training for student officers covering risks, signs, symptoms, situational awareness, communication and response.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Implement scenario-based PPST Foundation and Recertification programmes assessing restraint, decision-making, communication, subject welfare and safety-officer use.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Mandate and roll out Safer Restraint e-learning on prolonged restraint, welfare monitoring, situational awareness and safety-officer responsibilities, with completion actively monitored.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025. View source
Action
Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source See 2 more actions
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AI-generated summary
Brian Thomas RINGROSE · 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
Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to check airways and breathing rate during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate , despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to listen to, interpret and respond to breathing during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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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 Review and publish mobile Snap Guides covering safety-officer duties, welfare monitoring, restraint, spit guards, acute behavioural disturbance and prone ground-pin risks.
Verbatim wording from the response “TVP have also reviewed and published the following Snap Guides. These are summary documents available to officers through their mobile devices and are designed to be used whilst operationally deployed. They address identified matters such as ineffective welfare monitoring; inadequate application of police restraint training and risks associated with handcuffing to the rear and prone restraint.” Source location Response from Thames Valley Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce positional-asphyxia training for student officers covering risks, signs, symptoms, situational awareness, communication and response.
Verbatim wording from the response “TVP have introduced a PowerPoint presentation on positional asphyxia into our Foundation Training for student officers. This presentation covers the definition of positional asphyxia, the position it may occur in including the increased risk around prone restraint, signs and symptoms and officer response. Officer response is centred on situational awareness, communication and decision-making. These areas promote the use of a safety officer where numbers permit.” Source location Response from Thames Valley Police
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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 Implement scenario-based PPST Foundation and Recertification programmes assessing restraint, decision-making, communication, subject welfare and safety-officer use.
Verbatim wording from the response “It is of note that there has been considerable National development of PPST by the College of Policing and NPCC, with new Recertification and Foundation programmes, introduced into TVP in November 2023 and April 2024 respectively. The introduction of these training programmes has seen the PPST portfolio evolve significantly since the time of the incident.” Source location Response from Thames Valley Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate and roll out Safer Restraint e-learning on prolonged restraint, welfare monitoring, situational awareness and safety-officer responsibilities, with completion actively monitored.
Verbatim wording from the response “In mid-March 2025, ACC Bunt delivered a force wide communication to all officers and staff. This included changes to training and guidance as a consequence of the death of Mr Ringrose. All police officers and police staff detention officers were mandated to complete an online E-Learning package titled ‘Safer Restraint.’ This training covers the medical issues that can arise with prolonged restraint, welfare monitoring, situational awareness and the importance of the role of Safety Officer. The completion of this learning is being actively monitored and to date 4760 Officers and Detention Officers have completed this training (95% of the target audience).” Source location Response from Thames Valley Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.
Verbatim wording from the response “d. Unsafe Communication Practices
To enhance the robustness and integrity of our documentation process, we have implemented a joint entry protocol. Under this approach, both assessors will contribute directly: the second assessor will either formally approve the initial entry or provide a complementary entry to ensure a more comprehensive and balanced record. Verbal handovers to the treating medic, or to the Nurse in Charge if the medic is unavailable, are now mandatory immediately post-assessment, followed by contemporaneous entries in ECare summarising the handover with a more detailed entry to follow based on the SystmOne entry. These changes aim to improve the” Source location Response from Central and North West London NHS Foundation Trust
Open published response
26 Feb 2021 Mr Joseph Agnew · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness View source Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns View source
This report raised 4 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.
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AI-generated summary
Mr Joseph Agnew · 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 Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness , nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction . He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention . The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
” Source location Mr Joseph Agnew · Prevention of Future Deaths report
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 train officers to effectively monitor breathing and recognise dangerous breathing patterns
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing . My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing . He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing .
” Source location Mr Joseph Agnew · Prevention of Future Deaths report
Open source report
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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 Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.
Verbatim wording from the response “The PCDA places a high level of emphasis on the potential vulnerability of a person who, because of their situation or circumstances, is unable to take care or protect themself from harm or exploitation. This includes the importance of considering the possibility of hidden medical conditions or non-visible signs that may lead to a person being vulnerable. The College has developed a vulnerability learning programme which supports the PCDA programme and can also be used for officers who have not been trained through the PCDA to ensure consistency in learning.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
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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 Align officers’ first-aid training with Metropolitan Police guidance on snoring, airway obstruction, jaw thrust, and breathing monitoring.
Verbatim wording from the response “I would, however, confirm that my instructions are that the first aid training of City of London Police officers will henceforth fall in line with that given to Metropolitan Police officers, who you heard are now trained specifically to recognise that snoring in a person with a reduced level of consciousness is a sign of airway obstruction which must be rectified and are taught to perform the “jaw thrust” that was described to you by ████████ the Metropolitan Police Service’s Senior Adviser, First Aid, Policy, Assurance and Training, in her evidence before you. DCI ████████ has confirmed that this will be thoroughly covered in the first aid training provided to City of London Police officers. Officers will be taught how to monitor breathing and will be taught not to seek to rely on being able to see the casualty’s chest rise and fall.” Source location 2021-0055-Response-from-City-of-London-Police-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review FALP learning outcomes to incorporate concerns about assessing intoxicated people, referral for medical attention, and monitoring breathing and symptoms.
Verbatim wording from the response “In addition, a wider review of the high level learning outcomes for the FALP has already been initiated to ensure that they remain fit for purpose. We will ensure that your causes for concern will form part of this review. It is anticipated that this work will be completed towards the end of 2021 following the publication of updates expected from the UK Resuscitation Council this year.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.
Verbatim wording from the response “The FALP has five modules and the national recommendation is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider). While Module 2 does not seek to provide detailed coverage of all specific medical conditions it does allow officers and staff to make an assessment of the casualty, including the known factors that may present a risk to their health.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.
Verbatim wording from the response “It is recognised that some areas of policing, such as working in custody environments, firearms operations or public order teams, require additional skills and knowledge. The relevant staff have additional FALP training modules available to ensure they are prepared for situations they are likely to encounter in their specialist roles. Additionally, where local force risk assessments identify a critical need, Chief Officers are able to add additional medical training provisions under the advice of local clinical governance.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
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29 Oct 2018 KARL BRUNNER · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Lack of knowledge of choking risks during arrest or detention View source
This report raised 2 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.
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AI-generated summary
KARL BRUNNER · 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
Karl Brunner died after choking on a package of drugs he swallowed while being arrested by police in Bedford on 11 May 2016. The report identified concerns that officers lacked knowledge of the risks of choking during arrest or detention and that the mouth and face guards provided to them were defective and inappropriate for high-risk suspects.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of knowledge of choking risks during arrest or detention
Wider context from the report “The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs. The evidence however disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained . This should urgently be addressed in the Officers’ training and the appropriate medical procedures should be adopted.
” Source location KARL BRUNNER · Prevention of Future Deaths report
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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 Provide annual first-aid training, including choking management, to officers, special constables, detention officers and Police Community Support Officers.
Verbatim wording from the response “4. Across Bedfordshire, Cambridgeshire and Hertfordshire police forces all officers, special constables, detention officers and Police Community Support Officers receive First Aid training at least annually on a rolling programme. Student officers receive training more often as it is incorporated within their two year probationary period. Thus training is provided in accordance with the standards set down by the College of Policing, which remain under review.” Source location 2018-0310-Response-by-Bedfordshire-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train officers and students to use choking training aids and demonstrate front-position thrusts when rescuers cannot encircle a casualty.
Verbatim wording from the response “5. Included within the training is a module which deals specifically with persons who are choking. It sets out the appropriate manner in which a choking detainee should be managed, and specifically incorporates the comprehensive lesson plan produced by the College of Policing. In particular, this includes:” Source location 2018-0310-Response-by-Bedfordshire-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give officers and custody staff instructions for managing detainees who place items in their mouths, swallow items or begin choking, including ambulance escalation and emergency life support.
Verbatim wording from the response “7. Officers and custody staff are given the following specific instructions in the event they are faced with a scenario similar to that which occurred during the detention of Mr Brunner. These are in line with the recommendations issued by the Independent Office for Police Conduct (“IOPC”) and state that:” Source location 2018-0310-Response-by-Bedfordshire-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regular choking training complies with IOPC recommendations and meets College of Policing standards.
Verbatim wording from the response “8. The regular training provided to all Bedfordshire Police officers complies with the recommendations of the IOPC and meets the standards set out by the College of Policing.” Source location 2018-0310-Response-by-Bedfordshire-Police
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29 Jun 2018 Rashan Jermaine CHARLES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure to recognise that apparent resistance may indicate a struggle to breathe View source Choking without classic visible signs View source
This report raised 2 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.
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AI-generated summary
Rashan Jermaine CHARLES · 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
Rashan Jermaine Charles entered a convenience store after a foot chase, put a package in his mouth, and was restrained and handcuffed during a struggle. He lost consciousness and suffered cardiac arrest; the recorded medical cause of death was cardiac arrest due to upper airway obstruction by a foreign body during restraint. Concerns included recognising choking when it resembles resistance, assessing breathing in stressful conditions, and managing assistance from members of the public.
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× 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 recognise that apparent resistance may indicate a struggle to breathe
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” Source location Rashan Jermaine CHARLES · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Choking without classic visible signs
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” Source location Rashan Jermaine CHARLES · Prevention of Future Deaths report
Open source report
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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 Provide recruit and three-yearly refresher training on recognising and treating choking, including cases without classic signs.
Verbatim wording from the response “The Programme Specification states in respect of choking: “An airway obstruction can be recognised by difficulty speaking, attempts to breathe or cough, increasing signs of asphyxia (blueness discolouration to face) and eventual loss of consciousness. Therefore, it is therefore made clear that individuals who are choking they may not be able to breathe or cough.” Source location 2018-0210-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.
Verbatim wording from the response “The importance of completing a thorough breathing check and regularly monitoring a subject’s breathing is central to ELS training. The training states that if breathing cannot be established because a subject is in the recovery position, they should be turned onto their back to facilitate a full breathing check. It further states that CPR should be commenced if there is any doubt.” Source location 2018-0210-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.
Verbatim wording from the response “The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.” Source location 2018-0210-Response-by-Metropolitan-Police
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20 Oct 2016 Susan Sian JONES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3
Failure to recognise snoring as a possible sign of life-threatening partial airway obstruction View source Failure to rouse individuals to assess whether snoring is benign View source Failure to account for alcohol or drug intoxication when assessing snoring View source
This report raised 4 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.
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AI-generated summary
Susan Sian JONES · 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
Susan Sian Jones suffered a cardiorespiratory arrest at Hornsey Police station while waiting to make a statement about an allegation of historical sexual assault. At inquest, the jury concluded that her death resulted from methadone and alcohol intoxication together with inadequate police policies, procedures and training. The report identified a lack of specific protocol or training for monitoring members of the public in police stations who are not in police custody.
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× 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 recognise snoring as a possible sign of life-threatening partial airway obstruction
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Source location Susan Sian JONES · Prevention of Future Deaths report
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 rouse individuals to assess whether snoring is benign
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing , most particularly by waking the individual and determining whether they are able to sit up and hold a conversation .
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Source location Susan Sian JONES · Prevention of Future Deaths report
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 account for alcohol or drug intoxication when assessing snoring
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant . In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking , even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Source location Susan Sian JONES · Prevention of Future Deaths report
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Includes failures in police recognition, assessment, training, policy or response controls specifically intended to identify breathing difficulty, abnormal breathing or airway obstruction during encounters with members of the public, including apparent resistance or reduced consciousness.
