15 Dec 2022 Neal Terence Saunders · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3
Incorrect training about ambulance response categorisation for ABD View source Failure of classroom-based ABD training to be retained and embedded View source Unclear applicability of restraint guidance to people under arrest View source
This report raised 5 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. 11
Action
Clarify in revised training and guidance that ambulance-service response is their responsibility and relevant information must be communicated for dispatch prioritisation.
Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Introduce a directive requiring phonetic transmission and receipt of acronyms during emergency-service handovers.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022. View source
Action
Work with TVP to ensure officers understand that call takers will contact them at scene to support accurate triage and ambulance-response categorisation.
Stated by South Central Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022. View source
Action
Update ABD and restraint training materials to clarify containment, ambulance response expectations, medical emergency status, and prohibited chemical-sedation references.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Implement the mandatory PPST package, updated national curriculum and APP, with nationwide rollout and ongoing College quality assurance.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022. View source
Action
Introduce the College of Policing’s new two-day PPST training and assessment reaccreditation programme for TVP personnel.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Deliver the interim PST Mod 1 reaccreditation package with ABD, restraint, de-escalation, medical-emergency, communication, scenario, and written-test components.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Incorporate organisational-learning content into First Aid and Medics training, with written knowledge and practical-skills assessment.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Update initial PPST and First Aid training programmes with ABD and restraint material, written testing, and practical-skills assessment.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022. View source
Action
Clarify in PPST content that the guidance applies to restraint in all circumstances, including arrest.
Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source See 8 more actions
×
AI-generated summary
Neal Terence Saunders · 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
Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.
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 Incorrect training about ambulance response categorisation for ABD
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Source location Neal Terence Saunders · 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 of classroom-based ABD training to be retained and embedded
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received . I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively .
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded ?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Source location Neal Terence Saunders · 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 Unclear applicability of restraint guidance to people under arrest
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified ).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Source location Neal Terence Saunders · Prevention of Future Deaths report
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 Clarify in revised training and guidance that ambulance-service response is their responsibility and relevant information must be communicated for dispatch prioritisation.
Verbatim wording from the response “3. We will ensure that the revised training and guidance makes it clear that the response from the ambulance service is a matter for them, and the important point for policing is to ensure that relevant information is communicated so that ambulance dispatchers can make appropriate decisions on prioritisation.” Source location Response from College of Policing
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 Meet and liaise with TVP, the College of Policing and AACE to review ambulance guidance and police training materials.
Verbatim wording from the response “To confirm, your Regulation 28 report was predominantly aimed at the national bodies responsible for providing training and guidance to police and ambulance service emergency personnel. Within that report, you asked the South Central Ambulance Service to consider working jointly with Thames Valley Police (TVP) to review our policies and training as suggested by our Medical Director during the evidence he provided to you.” Source location Response from South Central Ambulance Service
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 Introduce a directive requiring phonetic transmission and receipt of acronyms during emergency-service handovers.
Verbatim wording from the response “b. In addition we have drafted a directive regarding using the phonetic alphabet to pass over and receive information from other emergency services. As you know, in this specific case, the incorrect information was provided to the Trust by TVP which affected the category of ambulance response initially required. Going forward, whilst the full name of the medical condition will always be confirmed, any acronyms will be handed over phonetically as well as minimise the risk of information being lost in translation.” Source location Response from South Central Ambulance Service
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 Work with TVP to ensure officers understand that call takers will contact them at scene to support accurate triage and ambulance-response categorisation.
Verbatim wording from the response “c. We are also working with TVP to ensure that their officers are aware that our call takers will attempt to contact them at the scene so that a more accurate triage can be undertaken. Whilst it is recognised it may not always be possible for a police officers to answer their telephone, it is important that police officers understand the process that will be followed so that the appropriate category of ambulance response can be arranged for the patient.” Source location Response from South Central Ambulance Service
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 Update ABD and restraint training materials to clarify containment, ambulance response expectations, medical emergency status, and prohibited chemical-sedation references.
Verbatim wording from the response “material on this issue has been updated to ensure that Officers understand this point.” Source location Response from Thames Valley Police
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 Implement the mandatory PPST package, updated national curriculum and APP, with nationwide rollout and ongoing College quality assurance.
Verbatim wording from the response “The College is currently implementing a new mandatory training package for Public and Personal Safety Training (PPST) along with an updated national curriculum and Authorised Professional Practice (APP). The nationwide roll out of this programme will commence in April 2023 and all forces must achieve implementation by April 2024. This will result in police forces delivering PPST to a common national standard which will be subject to an ongoing quality assurance process by the College. The training is a two-day annual package which is delivered in person and is focused on supporting learners with information retention.” Source location Response from College of Policing
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 Introduce the College of Policing’s new two-day PPST training and assessment reaccreditation programme for TVP personnel.
Verbatim wording from the response “• In April 2023, the College of Policing are introducing a new PPST 2-day training and assessment re-accreditation programme for all Forces nationally. The new programme will be based around six scenarios to aid officer’s learning and the retention of knowledge and skills. Forces have until the end of March 2024 to introduce the new programme, which is due to go live in TVP on 14th November 2023.” Source location Response from Thames Valley Police
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 Deliver the interim PST Mod 1 reaccreditation package with ABD, restraint, de-escalation, medical-emergency, communication, scenario, and written-test components.
Verbatim wording from the response “• Before the introduction of the new CoP PPST programme, TVP will be re-accrediting Officers and Staff who require re-accreditation prior to November with an updated training package. Delivery of the new 1-day package (called PST Mod 1) will start on 2nd March 2023 through to November 2023.” Source location Response from Thames Valley Police
Open published response
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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 Incorporate organisational-learning content into First Aid and Medics training, with written knowledge and practical-skills assessment.
Verbatim wording from the response “• To reinforce the organisational learning further, TVP will also ensure that additional training material is included within all First Aid and Medics training programmes from the 1st May 2023. This will ensure that Officers and Staff who have direct contact with the public will receive key aspects of this learning within both their mandatory training inputs (PPST) and First Aid re-accreditation, i.e. twice in any year).” Source location Response from Thames Valley Police
Open published response
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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 Update initial PPST and First Aid training programmes with ABD and restraint material, written testing, and practical-skills assessment.
Verbatim wording from the response “Initial Training (Police Officer, Police Community Support Officer, Special Constable, Detention Officer):” Source location Response from Thames Valley Police
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 Clarify in PPST content that the guidance applies to restraint in all circumstances, including arrest.
Verbatim wording from the response “2. The new PPST content will be clear that the guidance applies to those who are restrained in any circumstances, including people who are under arrest.” Source location Response from College of Policing
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 Ambulance service response decisions are its responsibility; policing’s role is to communicate relevant information for ambulance dispatch prioritisation.
Verbatim wording from the response “3. We will ensure that the revised training and guidance makes it clear that the response from the ambulance service is a matter for them, and the important point for policing is to ensure that relevant information is communicated so that ambulance dispatchers can make appropriate decisions on prioritisation.” Source location Response from College of Policing
Open published response
28 Oct 2022 Jade Hutchings · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Inadequate police mental health training 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
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
Enhance and update initial mental-health training for all new officers, including legal powers, vulnerability, equality and cultural influences.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Deliver mandatory mental-health continuing professional development, including College of Policing e-learning and related legislation, incident-response and suicide-response modules.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Deliver mental-health content through mandatory personal-safety, inspector and custody-officer training, including crisis recognition, de-escalation and Section 136 procedures.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source
Action
Deliver mental-health training to all control-room operators, including guidance on mental-health-related calls and Section 136 detentions.
Stated by Sussex PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022. View source
Action
Develop and deliver mental-health and policing training under oversight from a mental-health social worker and in line with College of Policing guidance.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 19 December 2022. View source See 2 more actions
×
AI-generated summary
Jade Hutchings · 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
Jade Hutchings, who was 18, had been struggling with his mental health and using alcohol and drugs. After going missing while under their influence, he was found hanging at home and died in hospital on 23 May 2020. Concerns included inadequate police mental-health training and a lack of early-intervention provision for older children through the REBOOT scheme.
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 police mental health training
Wider context from the report “1. Inadequate Police training on Mental Health
During the course of the Inquest officers involved in dealing with Jade (and in particular around the exercise of their Section 136 powers on 21/5/20) acknowledged that they had received very little mental health training . Some officers could not recall any additional training provided since their initial training when they first joined the force .
The officers admitted that although they were aware of the Sussex Police mental health guide they had not read it in full.
The expert police witness, ████████, told the Inquest that in his view the online training provision that we were told was being rolled out in Sussex was not sufficient . None of the officers involved in this case had yet undertaken this online training .
It was his opinion that officers should be provided with the nationally recognised two day training course written by the College of Policing, The course is available for all Police forces to be rolled out locally. This training had not been adopted by Sussex Police .
There was also confusion amongst Officers (and a lack of clear understanding) around the provision and use of service the Haven at Millview could provide.
” Source location Jade Hutchings · 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 Enhance and update initial mental-health training for all new officers, including legal powers, vulnerability, equality and cultural influences.
Verbatim wording from the response “Mental health training is provided to all Student Officers in Sussex during their initial training programme. In December 2020 the initial training package was enhanced and again updated in March 2022. The training being delivered to all new officers joining Sussex Police at the time of writing (December 2022) is set out below.” Source location Response from Sussex Police 21.12
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 Deliver mandatory mental-health continuing professional development, including College of Policing e-learning and related legislation, incident-response and suicide-response modules.
Verbatim wording from the response “1. The College of Policing e-learning module. – Mental Health and the Police
This module has already been included in our CPD programme and all response officers must have completed this as part of the CPD schedule in 2022.” Source location Response from Sussex Police 21.12
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 Deliver mental-health content through mandatory personal-safety, inspector and custody-officer training, including crisis recognition, de-escalation and Section 136 procedures.
Verbatim wording from the response “Personal Safety Training” Source location Response from Sussex Police 21.12
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 Deliver mental-health training to all control-room operators, including guidance on mental-health-related calls and Section 136 detentions.
Verbatim wording from the response “Current courses now include a mental health training input on the following mandatory courses:” Source location Response from Sussex Police 21.12
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 Develop and deliver mental-health and policing training under oversight from a mental-health social worker and in line with College of Policing guidance.
Verbatim wording from the response “All training that is delivered by Sussex Police on Mental Health & Policing is in line with the College of Policing’s APP on Mental Health & Policing and is currently developed and delivered with oversight from a mental health social worker.” Source location Response from Sussex Police 21.12
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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 College of Policing does not deliver the purported two-day classroom course, and forces have discretion over which programme elements officers undertake.
Verbatim wording from the response “The comments and concerns of the Expert Police Witness, ████████ in relation to Sussex officers undertaking the College of Policing (CoP) two-day training course, have been carefully considered. The College of Policing do not deliver a two-day classroom-based learning course but do offer a ‘Mental Health Programme’ (published in October 2021) intended to support the Police Service to develop and deliver their own ‘in house’ training programme. The College of Policing recommend a ‘target audience’ for each module of their Mental Health Programme and individual forces are given discretion as to who would be more appropriate to attend specific parts of the programme; for example, the target audience for developing a strategic response to mental health is aimed at Inspectors and above up to and including NPCC and police staff equivalent.” Source location Response from Sussex Police 21.12
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25 Oct 2022 John Henry WHITE · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to provide bespoke training to frontline officers for handling similar situations View source
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.
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AI-generated summary
John Henry WHITE · 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
John Henry White suspended himself on 20 October 2019 and was transferred to Royal Glamorgan Hospital, where he died on 23 October 2019. The inquest jury concluded that the failure to release the ligature sooner possibly contributed to his chances of survival. The principal concerns were the incomplete distribution of ligature cutters to frontline officers and the availability of bespoke training for officers responding to similar incidents.
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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 provide bespoke training to frontline officers for handling similar situations
Wider context from the report “2. A collateral concern, not directly causative of Mr White’s death, arose during the inquest and which I also wish to bring to your attention.
This concerns the availability of bespoke training to response officers in relation to handling similar situations faced by the officers on the 20th of October 2019.
The three attending officers on 20.10.19 indicated that they had not received specific training (notwithstanding the evidence I received from retired Detective Chief inspector ████████ that he had prepared a video for officers covering this type of scenario as part of mental health awareness training in 2017) to assist them in managing the scenario they faced.
Retired Detective Chief Inspector ████████ indicated that he had delivered training that year to officers within the force for the purposes of cascading the same widely.
Given both the statistical and anecdotally evidenced increase in mental health crisis incidents (on occasions resulting in death) that your officers are required to attend, I believe that it would be of benefit to those officers who have not received this bespoke training , (as well, perhaps those who may benefit from refreshing their knowledge) for consideration to be given to retaining the same and expediting its delivery widely – i.e. to all frontline staff.
I would stress that the two immediate response officers cannot be, nor indeed were, criticised in their individual interactions with Mr White on the 20th October 2019. Indeed, and without the apparent benefit of the training, they interacted with Mr White in accordance with the approach advocated by retired Detective Chief Inspector ████████.
” Source location John Henry WHITE · Prevention of Future Deaths report
Open source report
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source
This report raised 11 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
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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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 police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” Source location Gaia Kima Pope-Sutherland · 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 Include epilepsy, psychosis, medical conditions, medication and associated risks in operational first-aid training.
Verbatim wording from the response “The content of Vulnerability 4 will also be built into initial training for Police Officers, Call Handlers and PCSOs to ensure ongoing development of new staff into the Organisation. Furthermore, in 2023, there will be a similar opportunity to raise awareness further in relation to epilepsy, psychosis, medical conditions, medication and the effect of such on and individual and subsequent risks. The Organisation will work with the clinical lead to ensure such are covered in the First Aid Training which is rolled out to operational officers and staff.” Source location Response from Dorset 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 Complete consideration of higher-level medical-condition training and conclude that the current policing approach remains appropriate.
Verbatim wording from the response “We have recently considered this question in relation to other conditions, such as neuro diversity, and further concluded that seeking to give a higher level of expertise is unfortunately not practical. Policing deals with an almost limitless variety of incidents, some situations or medical issues may only being encountered by officers very rarely – their training would be almost irrelevant because of the time that had lapsed between the training and the time the knowledge was needed to deal with the incident.” 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 Responsibility for national training updates on life-threatening illnesses rests with the College of Policing through its clinical governance process.
Verbatim wording from the response “This concern is directed to Chief Constable ████████ at the College of Policing. I wish to formally record my support for the learning from the inquest in relation to life-threatening illnesses to be shared with the College to inform National knowledge and understanding. I have personally written to CC Marsh to offer to support this work and to utilise the Organisation’s learning from Gaia’s inquest to inform and enhance any National training provision. I am aware that any updates to training and information relating to medical issues would go through the College of Policing clinical governance group for appropriate oversight and to ensure guidance was implemented.” Source location Response from Dorset 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 first aid, vulnerability training and authorised professional practice are considered proportionate and appropriate for responding to medical risks.
Verbatim wording from the response “We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good questions that enable an informed understanding of the range or risks affecting a missing person, on a case by case basis, to identify their severity and impact. Additionally, police responders should seek information from informed sources, such as family or doctor, to understand the impact and degree of any medical conditions potentially affecting a missing person.” 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 Comprehensive training on epilepsy and mental health conditions is considered impractical because medical conditions and missing-person circumstances are too complex and variable.
Verbatim wording from the response “Additionally, the College is committed to providing the highest standards of training for those working in policing however, that training also must be accessible and practicable. Medical conditions can be very complex, those conditions in themselves can be variable and they do not exist in isolation. Different conditions have differing levels of severity that interact with the myriad of circumstances in which people go missing. The quantity of variables is simply too great to reasonably and effectively train.” Source location Response from College of Policing
Open published response
26 Nov 2021 Gary Williams · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Lack of training on temporal lobe epilepsy-related ictal automatism during restraint View source
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
Gary Williams · 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
Gary Williams died on 28 July 2017 after a pulmonary thromboembolism and deep venous thrombosis, with ictal automatism due to temporal lobe epilepsy also recorded as a cause. The report describes concerns about the lack of detailed information passed during handovers, omissions in medical records concerning restraint, use of force and injuries, and inconsistent communication between hospital departments. It also notes that ictal automatism was not included in College of Policing training materials on restraint.
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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 training on temporal lobe epilepsy-related ictal automatism during restraint
Wider context from the report “Gary Williams suffered from Temporal lobe epilepsy. He was a retired police officer who was a very friendly and polite gentleman, when not unwell. He had previously had absences. However, nothing that can compare with the events in the eleven days before his death on the 28th July 2017. On the 18th July 2017 he suffered from an extreme acute behavioural disturbance, described as what appeared to be a psychotic delusional state in which array and violence to life and property was demonstrated. This was Ictal automatism due to temporal lobe epilepsy. A neurologist explained at the inquest that he felt sorry for the police, as they did not know the patient or with what they were dealing. He explained that there was no way to rationalise with some in this state - they are like a zombie and though they do not feel pain the use of PAVA, baton strikes and restraint will be responded to by the person’s fight and flight instincts. It is important to approach such a person with calm. In a neurological ward, it can take four experience health care professional and a fifth to sedate to deal with such a presentation. There is no treatment as such for this presentation just sedation and if necessary critical care support until the person has recovered. This condition is not part of the college of policing training materials with regard to use of restraint. You may consider that it would be helpful to include it in the minimum of 12 hours future mandatory annual restraint refresher training undertaken by all officers. In this case, officers, members of the public and health care professionals were distressed and exhausted but fortunately officers, healthcare professionals and the public did not suffer permanent serious or fatal harm.
” Source location Gary Williams · 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 Review and update the ABD PowerPoint and Personal Safety Training Manual with additional restraint training.
Verbatim wording from the response “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.” Source location 2021-0401-Response-from-NPCC_Published
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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 Obtain specialist emergency and forensic medicine advice on ABD training materials and trainer guidance.
Verbatim wording from the response “Specialist advice was sought from experts in emergency and forensic medicine who provided expert advice to SDAR relating to the ABD PowerPoint, notes for trainers and the National Personal Safety Manual.” Source location 2021-0401-Response-from-NPCC_Published
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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 Update and circulate the ABD Training Package for UK police forces, directing immediate delivery of the revised package.
Verbatim wording from the response “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.” Source location 2021-0401-Response-from-NPCC_Published
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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 Circulate emergency medicine best-practice guidelines on excited delirium and acute behavioural disturbance to police forces.
Verbatim wording from the response “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.” Source location 2021-0401-Response-from-NPCC_Published
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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 Continue reviewing learning from coroners, oversight bodies, stakeholders and police forces to inform restraint and self-defence training.
Verbatim wording from the response “The Self Defence Arrest and Restraint (SDAR) working group led by DAC ████████, works closely with the College of Policing. This group reviews the learning from coroners, the Independent Office of Police Conduct (IOPC), Her Majesty’s Inspectorate of Constabularies and Fire and Rescue Services (HMICFRS), stakeholders and police forces.” Source location 2021-0401-Response-from-NPCC_Published
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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 ABD training materials and package updates address the concern, with the arrangements remaining subject to continual review.
Verbatim wording from the response “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.” Source location 2021-0401-Response-from-NPCC_Published
Open published response
4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks 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
LEON BRIGGS · 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
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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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 Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks
Wider context from the report “2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders
Although, the MHCCG Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia . Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
” Source location LEON BRIGGS · 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 Deliver Acute Behavioural Disorder and positional-asphyxia training to frontline staff through the annual clinical update.
Verbatim wording from the response “EEAST has also developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia. The commencement of this training session is planned for 2021/2022 for all frontline staff across EEAST as part of the Essential Care Skills, which is EEAST’s annual clinical update.” Source location 2021-0330-Response-from-East-of-England-Ambulance-Service_Published
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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 organisation cannot mandate the content or depth of training required for frontline responders.
Verbatim wording from the response “With regard to your matter of concern around lack of sufficient training for police officers, ambulance crew and other front-line responders and the critical issues of recognising and responding to a medical emergency and the effects of restraint. We are unable to mandate the training that is required, nor the depth and degree of training. This is for local ambulance trust determination. However, we are very aware of the need for emphasis on and relevant training in this important area.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 Local ambulance trusts are responsible for determining the required training content and depth.
Verbatim wording from the response “With regard to your matter of concern around lack of sufficient training for police officers, ambulance crew and other front-line responders and the critical issues of recognising and responding to a medical emergency and the effects of restraint. We are unable to mandate the training that is required, nor the depth and degree of training. This is for local ambulance trust determination. However, we are very aware of the need for emphasis on and relevant training in this important area.” Source location 2021-0330-Response-from-Association-of-Ambulance-Chief-Executives_Published
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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 policing guidance and training are considered sufficient, so a separate document adapting the NHS Patient Safety Alert is unnecessary.
Verbatim wording from the response “The College of Policing has issued updated Authorised Professional Practice (APP), and provides ‘College Learn’ (formerly NCALT) with regards Officer Safety Training, First Aid and Mental Health Awareness. These packages have been updated significantly since 2013 to reflect learning with regards to awareness of Acute Behavioural Disturbance (ABD) and principles of detainee monitoring.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
23 Sep 2021 Hamish John Cameron HOWITT · Prevention of Future Deaths report West Sussex
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Concerns raised 2
Absence of directives in police training material and national policy on referral of apparently intoxicated injured people View source Insufficient police training to identify and refer apparently intoxicated people complaining of injury 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
Hamish John Cameron HOWITT · 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
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
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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 Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Source location Hamish John Cameron HOWITT · 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 Insufficient police training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Source location Hamish John Cameron HOWITT · 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 Circulate essential head-injury guidance to all officers, requiring medical assistance to be requested or facilitated where a head injury is suspected.
Verbatim wording from the response “i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 Send essential head-injury guidance to all first-aid trainers.
Verbatim wording from the response “ii. All first aid trainers have been sent the essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 essential head-injury guidance to Modules 1, 2 and 4 casualty-assessment training.
Verbatim wording from the response “iii. The lesson plan for Modules 1, 2 and 4 for “Assess a Casualty (Primary and Secondary survey)” has been amended to require this training to provide the same essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 essential head-injury guidance to Modules 3 and 4 head-injury training.
Verbatim wording from the response “iv. The Module 3 and 4 first aid training on head injuries has been amended to incorporate the same essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 Incorporate head-injury response guidance into Taser, Personal Safety and Public Order training programmes.
Verbatim wording from the response “v. Avon and Somerset Constabulary officers with responsibility for leading force training in relation to Taser, Personal Safety Training and Public Order training have also been made aware of the Report and of the first aid guidance on head injuries, which have been incorporated into their training programmes.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 Update first-aid training, policy or guidance when revised CoP or NPCC requirements are received.
Verbatim wording from the response “18. Avon and Somerset Constabulary will update its training provision immediately on receipt of any updated guidance from the CoP and / or NPCC.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 Send this response and relevant updated force guidance and training documents to the CoP and NPCC for consideration in national guidance and training decisions.
Verbatim wording from the response “19. A copy of this response, and relevant updated force guidance and training documents, will also be sent to the CoP and the NPCC so that they are aware of all of the changes that have been made internally by Avon and Somerset Constabulary, and can take these into consideration when determining whether any additional national guidance, or amendments to training provision are required.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 Continue reviewing the concerns and working with the CoP and NPCC to implement recommended changes to training, policy and guidance.
Verbatim wording from the response “17. It is understood that all matters of concern identified at Part 5 of your Report will be reviewed by the NPCC and CoP, including provision of training on head injury, the potential impact of alcohol in masking other underlying conditions, and your recommendations in relation to training material and national policy setting.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 FALP learning outcomes with clinical leads and assess adding stronger coverage of alcohol, intentional overdoses, and head injuries to Module 2.
Verbatim wording from the response “As a matter of course, all coroner reports and requests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. The College is also working with clinical leads to review the high-level learning outcomes within the FALP with the aim of placing greater emphasis on the training elements that preserve life. The review is already considering addressing the issue of acute alcohol intoxication and intentional overdoses within Module 2. It is also considering extending the learning in relation to head injuries to Module 2. The matters of concern you raise with relation to the impact of alcohol and the assessment of head injuries will be raised formally at the next meeting (13th December) to assess whether it is feasible and practicable to address these concerns within the scope of the licence.” Source location 2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
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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 first-aid training and formal governance routes will address the concerns about police responses to injured or vulnerable people.
Verbatim wording from the response “My officials have consulted College of Policing and National Police Chiefs Council (NPCC) on their response to your report. As mentioned in their joint letter, front line response police officers receive training at least equivalent to HSE Emergency First Aider level. Our police are required to deal with a wide range of situations on a daily basis and this includes working closely with ambulance services and other medical colleagues when responding to certain medical incidents, where appropriate.” Source location 2021-0320-Response-from-Home-Office_Published
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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 range of incidents makes it impracticable to train all officers for every medical emergency or specify a response for every context.
Verbatim wording from the response “Officers are called on to provide first aid in a wide range of incidents as part of their role. The range of incidents they attend mean it is not possible or viable for all officers to be trained for all types of medical emergencies, or for the FALP to explicitly outline the appropriate medical response in every context. That said, as detailed in this response, we acknowledge there is more that we can do to standardise our training and I trust that we have provided you with assurances that the matters of concern you have raised will be addressed.” Source location 2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
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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 CoP and NPCC are responsible for determining national FALP training and policy changes; the Constabulary will follow their updated guidance.
Verbatim wording from the response “ii. The CoP is working with clinical leads to review the high level learning outcomes with the aim of placing greater emphasis on the training elements that preserve life, and is presently considering:” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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30 Mar 2020 KAREN JANE BINGHAM · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure of police mental health training to provide information about behaviours associated with common mental health conditions View source
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.
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AI-generated summary
KAREN JANE BINGHAM · 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
Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch 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 of police mental health training to provide information about behaviours associated with common mental health conditions
Wider context from the report “1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
” Source location KAREN JANE BINGHAM · 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 Deliver a one-day common-mental-health-conditions training session to all Contact Centre staff.
Verbatim wording from the response “The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day training session for all of their staff on common mental health conditions later in 2020 to help those dealing with the public over the telephone recognise signs and symptoms.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-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 Mandate the revised online Mental Health training package for all officers and staff, including recognition of common behaviours.
Verbatim wording from the response “There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_Redacted
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10 Feb 2020 Ms Kerry Aldridge · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Insufficient mental health training for Sexual Offences Investigation Trained officers 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.
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
Ms Kerry Aldridge · 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
Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.
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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 Insufficient mental health training for Sexual Offences Investigation Trained officers
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health . ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice.
” Source location Ms Kerry Aldridge · Prevention of Future Deaths report
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7 Feb 2020 Mark Oliver George Mallinson · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to provide suicide intervention training to all frontline police staff View source
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
Mark Oliver George Mallinson · 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
Mark Oliver George Mallinson made numerous threats to take his own life over several hours after police sought to arrest him, and he died by suicide between 03.20am and 04.24am on 3 December 2018. The principal concern was that suicide-intervention training designed to save lives was not being provided to all frontline police staff.
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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 provide suicide intervention training to all frontline police staff
Wider context from the report “████████ provided a statement about the training given to police officers in the area of suicide intervention. ████████ stated that he had created a training package for new recruits. This training is designed to give first responders pointers to save lives and to buy time.
I received further information during the course of the inquest that most new recruits of Sussex Police in the last 12-18 months had received the training. However this training is not being rolled out to the remainder of the police force. The concern I have is that training specifically designed to save lives is not being provided to all front line staff.
” Source location Mark Oliver George Mallinson · Prevention of Future Deaths report
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Includes police training failures specifically affecting recognition or response to mental ill-health, acute behavioural disturbance, epilepsy or other medical crises presenting through behaviour.
