Recurring concern

Unsafe use of incapacitant spray when detainees have objects in their mouths

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First reported 1 Mar 2017•Latest report 27 Jun 2019

Definition

What this concern includes

Includes failures in guidance, procedures, training or operational decision-making specifically governing the use of PAVA, CS or comparable incapacitant spray when a person is believed to have an object in their mouth, including whether deployment is permitted, restricted or requires an alternative response.

Not included

Excludes generic incapacitant-spray training, policy or deployment concerns where no object-in-mouth or airway-obstruction risk is identified.
Excludes airway-management, choking-treatment or resuscitation failures after spray deployment where the spray-use decision itself was appropriately governed.
Excludes risks from other restraint methods, force options or chemical agents unless the assertion concerns the same object-in-mouth incapacitant-spray process.
Excludes ordinary possession or ingestion of objects where no deficient decision or control concerning incapacitant-spray use is asserted.

Reports: 2
Individual concerns: 2
Date range: 2017–2019
Stated actions: 2

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

Metropolitan Police Service1

National Police Chiefs’ Council1

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.

27 Jun2019
East London
Concerns raised1
1. Inadequate guidance and procedures for CS spray use when a person has an item in their mouth
This report raised 9 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 2
1. Action
  Add tactical-option assessment, justification, and recording guidance for suspected swallowed drugs to refresher training.
  Stated by Metropolitan Police ServiceStated planned
2. Action
  Review and consult on National Personal Safety Manual medical-implications guidance concerning irritant spray and airway risk before publication.
  Stated by Metropolitan Police ServiceStated in progress
Respondent positions 1
1. Position
  Evidence that CS spray worsens airway obstruction was theoretical and unsupported by firm evidence; further medical research was therefore being pursued.
  Stated by Metropolitan Police ServiceDisputes the concern
AI-generated summary

Edir Frederico Araujo DA COSTA · 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

Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance service.

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
Inadequate guidance and procedures for CS spray use when a person has an item in their mouth
Wider context from the report
“(4) The evidence given at the Inquest hearing revealed a concern that the use of CS spray, when a person has something in their mouth, could increase the risk of a complete airway obstruction. The MPS is requested to review the guidance and procedures in place for officers, in relation to the use of CS spray where a person is believed to be holding items in their mouth. ”
Source location
Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
Page 2 · 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
Add tactical-option assessment, justification, and recording guidance for suspected swallowed drugs to refresher training.

Verbatim wording from the response
“The OST refresher training programme will include lessons to reference consideration of tactics when faced with a person intent on trying to swallow drugs, assessing all tactical options and justification, accounting and recording of which options were considered as well as used. This is in line with wider existing National Decision Model training. Module 4 of the NPSM (entitled Medical Implications) is currently under review to reflect the irritant position and will state there is no current conclusive study confirming irritant spray as a causative factor, however care should be taken. Consultation with stakeholders will take place prior to publication.”

Source location
2019-0211-Response-by-Metropolitan-Police
Page 3 · response
Published 23 August 2019
Open published response
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 consult on National Personal Safety Manual medical-implications guidance concerning irritant spray and airway risk before publication.

Verbatim wording from the response
“The OST refresher training programme will include lessons to reference consideration of tactics when faced with a person intent on trying to swallow drugs, assessing all tactical options and justification, accounting and recording of which options were considered as well as used. This is in line with wider existing National Decision Model training. Module 4 of the NPSM (entitled Medical Implications) is currently under review to reflect the irritant position and will state there is no current conclusive study confirming irritant spray as a causative factor, however care should be taken. Consultation with stakeholders will take place prior to publication.”

Source location
2019-0211-Response-by-Metropolitan-Police
Page 3 · response
Published 23 August 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
Evidence that CS spray worsens airway obstruction was theoretical and unsupported by firm evidence; further medical research was therefore being pursued.

Verbatim wording from the response
“The MPS has considered the expert testimony of ████████ provided at the Inquest during which he said that “…it is theoretically possible that CS spray in those circumstances could perhaps make airway obstruction worse” (page 201 of transcript dated 29th May 2019). To emphasise that he was making a theoretical point only, he further added “I am not an expert on CS spray, it is something I have looked up …. There is to my knowledge no firm evidence for what I am saying, it is a rational opinion (pages 200-201 of the court transcript dated 29th May 2019).”

Source location
2019-0211-Response-by-Metropolitan-Police
Page 3 · response
Published 23 August 2019
Open published response
1 Mar2017
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth
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.

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

Darran Hunt · 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

On 8 February 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.

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 on deploying PAVA spray when a detainee is believed to have placed something in their mouth
Wider context from the report
“1. Use of PAVA Spray It has been suggested by the expert during the course of the Inquest that “luck” will determine whether a person sprayed with PAVA spray will inhale or exhale at the point immediately after being sprayed. There is clearly a risk therefore that a person with an object in their mouth could choke on that item if they inhale immediately upon being sprayed. At present there does not appear to be any guidance for officers on whether they should use PAVA spray in the circumstances of this case. Consideration needs to be given to whether guidance/policy should be issued to officers about if and when PAVA spray should ever be deployed in respect of a detainee who is believed to have placed something in their mouth. ”
Source location
Darran Hunt · 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

Inadequate guidance and procedures for CS spray use when a person has an item in their mouth

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth

Actions described in response 2

Respondent positions 1