Recurring concern

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

First to latest report 1 Mar 2017 — 27 Jun 2019

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
2

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.

What is 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 and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    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

  2. Carmarthenshire and Pembrokeshire

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026