3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Lack of formal measurement of ABD training knowledge View source Failure of ABD training to enable recognition in real-life settings 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.
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Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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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 formal measurement of ABD training knowledge
Wider context from the report “2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer . A more formalised approach may have increased the ability of officers to recognise ABD;
” Source location Andre Felipe Mendes Moura · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ABD training to enable recognition in real-life settings
Wider context from the report “1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting . The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation . The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD;
” Source location Andre Felipe Mendes Moura · 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 Use observed scenario assessments, knowledge checks and pass-or-fail decisions to test officers’ responses to acute behavioural disturbance.
Verbatim wording from the response “The new PPST is designed to be an interventionalist style of training delivery. The trainers observe the students managing the scenarios. The training is stopped at regular intervals when the trainers will test the knowledge of the students and get the students to explain the rationale for their decisions. PPST is a pass or fail course.” Source location Response from College of Policing
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quality-assurance and licence-moderation visits to check forces’ compliance with the new national training standards.
Verbatim wording from the response “Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised First Aid Learning Programme with a learning outcome requiring recognition of acute behavioural disturbance signs and symptoms.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance and treatment of head injuries.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement scenario-based Public and Personal Safety Training covering ABD recognition, de-escalation, containment, medical emergencies and immediate medical assistance.
Verbatim wording from the response “The new Public and Personal Safety Training (PPST) for all police officers has recently been developed with the emphasis on de-escalation. It is a scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and debriefing decisions. The updated training will include identification of the signs and symptoms of ABD and management of the incident with the focus now being on de-escalation and ‘contain rather than restrain’, where officers suspect a person to be experiencing ABD. There will also be an emphasis on treating ABD as a medical emergency and seeking immediate medical assistance.” Source location Response from College of Policing
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised acute behavioural disturbance training package.
Verbatim wording from the response “The new PPST training implementation went live in 2023 and forces are required to have implemented or be in the process of implementation by April 2024. The revised ABD training package will be published mid-September 2023.” 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 The College of Policing is responsible for addressing the four concerns concerning personal safety and Acute Behaviour Disturbance training.
Verbatim wording from the response “I note you set out five areas of concern, four of which focus on College of Policing Personal Safety Training, with particular focus on Acute Behaviour Disturbance (ABD). I am aware the College of Policing have written to you separately to address these points and have shared the timeframes for implementation of new Public and Personal Safety Training and revised ABD training.” Source location Response from National Police Chief's Council
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15 Dec 2022 Neal Terence Saunders · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure of classroom-based ABD training to be retained and embedded View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
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 See 2 more actions
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Neal Terence Saunders · Prevention of Future Deaths report
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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.
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce 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
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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 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
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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 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
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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 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
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27 Jan 2022 Adam Marshall Elliot STONE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to allow a category 1 ambulance response for severe ABD involving restraint View source
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Adam Marshall Elliot STONE · Prevention of Future Deaths report
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Report summary
Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.
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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 allow a category 1 ambulance response for severe ABD involving restraint
Wider context from the report “5. The continuance of a system which does not allow a category 1 response in severe case of ABD where restraint is taking place is putting lives at risk.
” Source location Adam Marshall Elliot STONE · 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 Propose that NHS England and AACE consider an evidence-based review of Acute Behavioural Disturbance response categorisation.
Verbatim wording from the response “I am aware that AACE will also be writing to you in response to your PFD. The College endorses the content of AACE’s letter to you. However, the College would always support an evidence-based review of the current response categorisation of Acute Behavioural Disturbance in order to ensure that a Category 2 response remains the appropriate disposition and I will share this correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose that such a review be considered in the light of this PFD.” Source location 2022-0026-Response-from-College-of-Paramedics_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 Write to ambulance services reminding them to provide senior-clinician oversight for ABD calls and upgrade to Category 1 when deterioration or restraint occurs.
Verbatim wording from the response “NHS England and NHS Improvement are in the process of writing to ambulance services regarding clinical oversight and will include a reminder that ABD calls should have oversight of a senior clinician in the control room and calls should be upgraded to a Category 1 if the patient’s condition deteriorates or if the patient is being restrained.” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_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 Conduct a joint police and ambulance review of suspected ABD presentations to assess deterioration risk and appropriate response categories.
Verbatim wording from the response “To help inform this decision and provide evidence, a joint police and ambulance review was conducted in the north of England between one ambulance service and a police force for a period of 9 months between August 2019 to May 2020. The purpose of the joint review was to establish whether individual presenting features in patients who were identified by police officers on scene as possible ABD, might individually or in combination reliably identify an increased risk of clinical deterioration associated with increased mortality and to determine the most appropriate ambulance response time category. Police officers identified 28 potential ABD cases in the nine-month review period, representing 1% of the mental health or behavioural crisis 999 calls attended by the police” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_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 Consider whether restraint alone should trigger an automatic Category 1 response for suspected ABD.
Verbatim wording from the response “We agree that ABD is not a diagnosis or a recognised syndrome, but rather a term used to describe a combination of signs and symptoms of agitation with likely physiological abnormalities, caused by one of a number of possible toxicological, physical, or mental health conditions. In the prehospital setting we are often unable to ascertain the exact cause of the presentation while providing clinical care prior to arrival at an emergency department. We considered whether the use of restraint alone should warrant an automatic Category 1 response, but this was agreed through the ECPAG process as not appropriate unless immediately life-threatening signs were present.” Source location 2022-0026-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 NHS Pathways recognises ABD and restraint risks and complies with the nationally mandated Category 2 response standard.
Verbatim wording from the response “We would like to reassure you that NHS Pathways recognises the risks associated with ABD/Excited Delirium and also that restraint may be a factor contributing to a patient’s deterioration.” Source location 2022-0026-Response-from-NHS-Digital_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 Any change to ambulance response categorisation must be considered by NHS England and AACE groups and approved by ECPAG.
Verbatim wording from the response “Therefore, any change in ambulance response categorisation would be matters for the respective” Source location 2022-0026-Response-from-NHS-Digital_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 Responsibility for determining NHS ambulance response categories lies with NHS England, supported by AACE evidence and guidance.
Verbatim wording from the response “The College of Paramedics is also not responsible for determining NHS ambulance response categories. That power lies with NHS England, although the Association of Ambulance Chief Executives (AACE) provide evidence and guidance to support this.” Source location 2022-0026-Response-from-College-of-Paramedics_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 Severe and mild ABD cannot be reliably distinguished during pre-hospital or telephone triage, so severity cannot determine the response category.
Verbatim wording from the response “ABD is not common and it is very difficult to identify the difference between agitation, antisocial behaviour, deliberate violent behaviour and ABD, which is not a specific condition with a set of defined symptoms. There is no reliable way to determine mild or severe ABD in the pre-hospital setting and certainly not on the phone during a triage process.” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_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 Suspected ABD appropriately receives a Category 2 response, with senior clinical oversight and escalation to Category 1 when the patient’s condition warrants it.
Verbatim wording from the response “Category 1 responses are reserved for immediate threat to life illnesses or injuries and ambulances are diverted when en-route to other emergencies in order to respond to Category 1 priorities. Cases of suspected ABD should be assigned a Category 2 response which is the immediate dispatch of an emergency ambulance, however, ambulance services are advised that a senior clinician within the control room should be made aware of the potential ABD incident to assist with decision-” Source location 2022-0026-Response-from-NHS-England-and-NHS-Improvement_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 AACE cannot decide or mandate emergency response categories and therefore cannot undertake that decision-making work.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-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 NHS England, through ECPAG, is responsible for deciding appropriate ambulance response categories.
Verbatim wording from the response “We need to highlight that the AACE is unable to make decisions nor mandate which category of response 999 callers receive, this is the responsibility of NHS England who chair and administer the Emergency Call Prioritisation Advisory Group (ECPAG) – a group of multi-disciplinary stakeholders who scrutinise evidence to support decisions about appropriate response categories for all clinical codes. AACE make recommendations to ECPAG based on clinical data submitted by ambulance trusts which is considered by National Ambulance Service Medical Directors (NASMeD) prior to any contribution to ECPAG discussion. Through this process the appropriate category of response for patients suspected of presenting with ABD was set by NHS England as a Category 2 response.” Source location 2022-0026-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 evidence-based arrangements consider Category 2 appropriate for suspected ABD unless immediately life-threatening signs warrant Category 1; restraint alone does not require Category 1.
Verbatim wording from the response “force. The review concluded that for patients who had been recognised as presenting with symptoms and signs of possible ABD, a Category 2 ambulance response was appropriate, if there was information that there were immediately life-threatening signs present, the patient should then receive a Category 1 ambulance response. The evidence and recommendations were accepted through the ECPAG process and implemented by all the UK ambulance services.” Source location 2022-0026-Response-from-Association-of-Ambulance-Chief-Executives_Published
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24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
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Concerns raised 5
Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source
Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 2 more concerns
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency 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 general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” Source location Douglas Paul Oak · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” Source location Douglas Paul Oak · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” Source location Douglas Paul Oak · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” Source location Douglas Paul Oak · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Source location Douglas Paul Oak · 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 Provide additional continuous professional development training on acute behavioural disturbance.
Verbatim wording from the response “Further to your letter dated 24th October 2019 regarding the Report to Prevent Future Deaths, I can confirm that St John Ambulance are providing additional Continuous Professional Development training around Acute Behavioural Disturbance.” Source location 2019-0352-Response-by-St-Johns-Ambulance
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 Raise acute behavioural disturbance coverage with the Tripartite Committee overseeing the First Aid Manual.
Verbatim wording from the response “As one of the co-authors of the First Aid Manual we have raised this at the Tripartite Committee who oversee the publication. The latest version of the manual is being written and we will push to get this topic covered.” Source location 2019-0352-Response-by-St-Johns-Ambulance
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 Press for acute behavioural disturbance to be covered in the forthcoming First Aid Manual edition.
Verbatim wording from the response “As one of the co-authors of the First Aid Manual we have raised this at the Tripartite Committee who oversee the publication. The latest version of the manual is being written and we will push to get this topic covered.” Source location 2019-0352-Response-by-St-Johns-Ambulance
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 Add ABD recognition and management to Module 2 of the First Aid Learning Programme for frontline refresher training.
Verbatim wording from the response “The College First Aid Learning Programme (FALP) already includes a learning outcome for recognising Acute Behavioural Disorder (ABD) as part of Module 3 (relating to first aid in a custody setting). In light of the above cause for concern the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.” Source location 2019-0352-Response-by-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 Review Module 4 of the National Personal Safety Manual and implement an agreed interim ABD information update.
Verbatim wording from the response “Officers undergo personal safety training (PST) every year with the content varying in line with national priorities and local need. The PST is informed by the content of the National Personal Safety Manual (NPSM) which is developed jointly by the College and NPCC and published to policing by the College. ABD training also sits within NPSM contained in Module 4: Medical Implications. This part of the Manual is currently undergoing a full review by Dr Meng Aw-Yong. This is in response to a number of changes that have been included over the past 12 months due to PFD notices. An interim update to the information has been agreed with Dr Meng and will be instigated in the near future. Each change to Module 4 is communicated to forces so that they and their PST trainers are aware.” Source location 2019-0352-Response-by-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 Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.
Verbatim wording from the response “The College and NPCC have developed a PowerPoint presentation on ABD which describes the behavioural and physical signs of ABD and makes very clear the need for rapid clinical assessment/intervention. The ABD PowerPoint was developed with the benefit of clinical input and was last updated in July 2019.” Source location 2019-0352-Response-by-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 Share the ABD presentation with NHS trusts and ambulance partners for appropriate use and adaptation.
Verbatim wording from the response “The ABD PowerPoint has already been shared with NHS Trusts and Ambulance partners. The PowerPoint is aimed at frontline police officers and the College and NPCC have made it clear that ambulance partners are at liberty to utilise and amend the PowerPoint, as appropriate, to meet the needs of their staff.” Source location 2019-0352-Response-by-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 Share the ABD presentation with the Tripartite Committee for consideration in the First Aid Manual.
Verbatim wording from the response “Recognising that concern about awareness of ABD extends beyond the police and ambulance services the College and NPCC will share the PowerPoint presentation on ABD with the Tripartite Committee who publish the First Aid Manual. The College and NPCC hope that this collaboration will increase knowledge of ABD amongst the first aid societies (St John Ambulance, The British Red Cross and St Andrews First Aid) and ultimately the public.” Source location 2019-0352-Response-by-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 Refresh the National Contact Management Learning Programme to include recognition of ABD as a medical emergency for call handlers and dispatchers.
Verbatim wording from the response “The College is in the process of refreshing the National Contact Management Learning Programme (NCMLP). This is a detailed set of learning standards that forces use to develop their local training for all contact management staff including those taking calls from the public and tasking and informing resources who respond. In this refresh we will include the importance of call handlers and dispatchers understanding the medical emergency that is ABD. This will complement the ABD presentation referred to below.” Source location 2019-0352-Response-by-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 Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Verbatim wording from the response “The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.” Source location 2019-0352-Response-by-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 Circulate the ABD presentation to force contact-management leads with advice on briefing control-room staff.
Verbatim wording from the response “the meantime the College will ask the NPCC national lead for Contact Management, ACC ████████ (Police Service of Northern Ireland) to circulate the ABD PowerPoint presentation to force leads, with advice on how this could be delivered locally to brief staff working in control rooms.” Source location 2019-0352-Response-by-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 Ensure frontline ambulance and control-room staff are made aware of the new acute behavioural disturbance guidance after publication.
Verbatim wording from the response “iii) Following the publication of the JRCALC guideline on ABD there will be an expectation that all statutory ambulance services will ensure that their frontline staff are aware of, and concomitant with, its contents and ambulance control staff are also made aware of the new guidance.” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
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 Pilot conflict-management and de-escalation training using role play, presentations and didactic learning.
Verbatim wording from the response “The College has produced Conflict Management Guidelines which contain information to assist in the development of de-escalation training and skills for front line staff. The College and NPCC will shortly be piloting conflict management/de-escalation training as part of its work to develop the national PST curriculum. The approach involves the use of role play as well as presentations and didactic learning. The College Guidelines recommend that role plays include resolution through de-escalation and of the medical impacts of any physical intervention used by learners.” Source location 2019-0352-Response-by-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 Share the control-room ABD presentation with ambulance service leadership bodies.
Verbatim wording from the response “The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.” Source location 2019-0352-Response-by-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 Develop joint ambulance-police guidance for responding to suspected acute behavioural disturbance.
Verbatim wording from the response “ii) Joint guidance between the statutory ambulance services and the Police Forces is in development, overseen by a joint committee of AACE and the National Ambulance Commissioning Network, and supported by the ambulance and mental health group in NHS England. NASMeD has requested development of ambulance guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and these are due to be ratified shortly. The guidelines have been developed following consultation with the Faculty of Forensic and Legal Medicine (FFLM) and the Faculty of Pre-Hospital Care (FPHC).” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
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 Development of First Aid manual content falls outside NASMeD and AACE involvement, so they cannot assist with that matter.
Verbatim wording from the response “i) NASMeD, and the Association of Ambulance Chief Executives (AACE) as its parent body, have no involvement in the development of the content of First Aid manuals and are therefore unable to assist with this matter.” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
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 Mandating ABD training more frequently than the existing cycle is considered disproportionate given staffing levels and the relative infrequency of suspected cases.
Verbatim wording from the response “Through first aid and PST officers will receive training focusing on ABD at least every three years and probably more frequently in practice. The first aid and PST training represent a minimum requirement, balanced against the other significant training police officers require for their role. It would not be” Source location 2019-0352-Response-by-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 Annual ABD refresher training is considered disproportionate because cases are infrequent and paramedics must maintain broad competencies.
Verbatim wording from the response “iv) Annual refresher training in ABD is disproportionate given the incidence of these cases and the need to maintain and develop the broad range of competencies required of a frontline paramedic in a statutory ambulance service. We believe each of the English ambulance services receives two or three calls each week for patients with suspected ABD, amongst two to four thousand 999 calls per day. Whilst NASMeD or AACE is not in a position to mandate training requirements, we would not support a recommendation for annual refresher training on this subject.” Source location 2019-0352-Response-by-Association-of-Ambulance-Chief-Executives
Open published response
16 Jul 2019 Mr Darren Keith Cumberbatch · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1
Lack of probation hostel staff awareness and training in relation to Acute Behavioural Disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Darren Keith Cumberbatch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Darren Cumberbatch became acutely agitated at a probation hostel and was taken to hospital after police used physical force, Tasers, incapacitant spray and a baton during restraint. He was treated for a suspected cocaine-related drug overdose, developed worsening kidney function and multi-organ failure, and died on 19 July 2017. The report raised concerns that probation hostel staff lacked awareness and training in Acute Behavioural Disturbance, including the importance of information sharing, de-escalation and minimising restraint.
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 probation hostel staff awareness and training in relation to Acute Behavioural Disturbance
Wider context from the report “v. National Probation service staff receive mandatory training which includes an aspect of substance misuse. The probation hostel staff had no awareness or training in relation to Acute Behavioural Disturbance.
vi. ABD is a potential medical emergency.
vii. Information sharing of an individual possibly suffering from ABD is very significant and those with a basic knowledge of it can be implemental in formulating a plan to manage a person suspected to be suffering with ABD which include the use of de-escalation techniques so as to minimalise the use of restraint.
viii. The police have basic training to recognise the signs / symptoms which can dictate as to how an individual is managed, in particular with regards to restraint (detain/ contain rather than restraint).
ix. West Midlands Ambulance call assessors receive information to determine the appropriate level of care at the point of a telephone call to the ambulance service. A patient suspected to be suffering with “ABD” is automatically a ‘category 2’ situation i.e. a potentially serious condition that may require rapid assessment with a response target time frame of 18 minutes.
x. Basic training for probation hostel staff (e.g. similar to simple basic training materials that are provided to the police by the college of policing to increase awareness of ABD) is possible and this may prevent future deaths. Such awareness combined with opportunities to engage with an individual and a familiarisation with residents may better aid in the de-escalation of a person suspected to be suffering with ABD and thereby potentially minimalizing the necessity to resort to any restraint (which can be very dangerous to a person suffering since restraint and struggle against restraint increases the acidosis in the body which can lead to muscle breakdown which can lead to rhabdomyolysis and multi organ failure). It may best facilitate the individual engaging willingly seeking the necessary medical attention.
” Source location Mr Darren Keith Cumberbatch · 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 Assess the most appropriate acute behavioural disturbance awareness training package for approved premises staff.
Verbatim wording from the response “In response to your recommendation I confirm that the National Probation Service now has plans in place to assess the most appropriate training package to meet this training requirement and to develop an implementation plan across the whole approved premises estate with the intention to start the roll out of ABD awareness training early in 2020.” Source location 2019-0289-Response-by-HM-Prison-Probation-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 Develop an implementation plan for acute behavioural disturbance awareness training across the approved premises estate.
Verbatim wording from the response “In response to your recommendation I confirm that the National Probation Service now has plans in place to assess the most appropriate training package to meet this training requirement and to develop an implementation plan across the whole approved premises estate with the intention to start the roll out of ABD awareness training early in 2020.” Source location 2019-0289-Response-by-HM-Prison-Probation-Service
Open published response
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7
Insufficient coverage of ED/ABD training for front-line response staff View source Training that conflates ED/ABD death risk with positional asphyxia View source Failure of the police Mental Health Guide to separately address ED/ABD View source
Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source See 4 more concerns
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Terrence Arthur Albert Smith · 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
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” Source location Terrence Arthur Albert Smith · 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 Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient.
” Source location Terrence Arthur Albert Smith · 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 the police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” Source location Terrence Arthur Albert Smith · 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 Police training that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Source location Terrence Arthur Albert Smith · 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 Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient .
” Source location Terrence Arthur Albert Smith · 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 Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” Source location Terrence Arthur Albert Smith · 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 Police training that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Source location Terrence Arthur Albert Smith · Prevention of Future Deaths report
Open source report
28 Jun 2017 Olaseni Lewis · Prevention of Future Deaths report South London
View report summary
Concerns raised 2
Inadequate definition of prolonged restraint and restraint danger in ABD training View source Failure of ABD training to provide clear and understood recognition guidance View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olaseni Lewis · 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
Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.
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 definition of prolonged restraint and restraint danger in ABD training
Wider context from the report “(3) Police were taught that prolonged restraint was dangerous, but had no idea what “prolonged” meant, and were left to use their own judgement . They also seemed to think that prolonged restraint referred to time spent in a prone position and that as long as the detainee was held on his/her side the danger was ameliorated or removed . The pathological and psychiatric expert evidence clearly indicated that restraint in any position can lead to sudden death in patients who are highly agitated . The jury found that the police training was inadequate in its definition of “prolonged restraint” for people exhibiting signs of ABD .
” Source location Olaseni Lewis · 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 ABD training to provide clear and understood recognition guidance
Wider context from the report “(2) Officers had been taught about Acute Behavioural Disturbance (ABD) but most did not recognise that Mr Lewis was suffering from ABD . The training on ABD appeared unnecessarily complicated and was not fully understood by officers . They incorrectly assumed that it was a formal diagnosis of some sort and that healthcare professionals would be able to recognise and treat the condition . An expert psychiatrist indicated that the description might be helpful for police in the community, particularly when the condition is caused by drugs, but it causes difficulty when police and mental health services work together and where the underlying cause is related to mental illness. The question that arose was whether it is necessary to attach a label at all. It might be more easily understood if officers are taught that people who resist restraint and appear to be suffering from mental illness may not respond as expected, and are therefore more vulnerable to die suddenly during restraint.
” Source location Olaseni Lewis · 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 Embed recognition and emergency treatment of suspected ABD in mandatory, assessed restraint training.
Verbatim wording from the response “In addition, the Officer Safety Training Programme (OST), which is pass/fail and mandatory for all officers below the rank of superintendent, reinforces each of the significant areas of information during the instructor-led modules. For example, the complex issues surrounding the condition that has come to be known as Acute Behavioural Disorder (ABD) forms a golden thread through regularly taught, refreshed and assessed modules within restraint training. In this way, officers become” Source location 2017-0205-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce safer-restraint training material jointly with South London and Maudsley NHS Trust.
Verbatim wording from the response “The potential confusion this term may cause when working with other mental health service providers highlighted in your report is however acknowledged. This barrier can be reduced through improved working relations with the police and health care professionals. Work in this area includes the production of the ‘Safer Restraint’ DVD by the MPS in partnership with South London and Maudsley NHS Trust (SLaM) and the ongoing work of the MPS Mental Health Team in support of the national Memorandum of Understanding (MOU) announced by the College of Policing in January 2017 (College of Policing, 2017). The MOU was provided to you as an appendix to ████████ statement dated 26/01/2017.” Source location 2017-0205-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an ongoing partnership with independent healthcare experts to inform restraint and officer-safety training.
Verbatim wording from the response “The Independent Medical Science Advisory Panel (IMSAP) is an ad hoc panel of leading independent healthcare professionals who advise the National Policing Lead for Personal Safety Training on medical matters relating to physical restraint and self-defence techniques and equipment. The MPS believes that this on-going partnership helps to ensure that its officers receive the best informed training on what remains a complex condition that can present in very challenging and often violent situations. The benefits of changing this approach, which is firmly embedded in national and MPS training, appear to be unclear and could undo much good work already achieved by the police service with medical partners.” Source location 2017-0205-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A specified restraint time limit will not be introduced because it lacks clinical basis and presents practical timekeeping difficulties.
Verbatim wording from the response “3. The introduction of time limits for prolonged restraint has been subject to much discussion in the police service. Advice from the Independent Medical Science Advisory Panel (IMSAP) was that there is no clinical basis for this due to the ‘many and various physiological factors that would preclude a firm medical basis for such an approach’ (Independent Medical Science Advisory Panel, 2014). The advice further cautioned that the introduction of a time limit could give rise to a misconception that restraint within this time period was safe. Doubts were also raised over the practicalities of accurate time keeping such events.” Source location 2017-0205-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ABD terminology and embedded training are considered sufficient; changing the approach has unclear benefits and could undo established work.
Verbatim wording from the response “2. It is widely recognised that the status of ABD remains a point of conjecture for many healthcare professionals. The police service in England recognised this but increasing phenomenon in the mid-90s and adopted the American terminology of Excited Delirium in mandatory training. The Senior Coroner heard evidence that the terminology was largely connected to the use of drugs, whereas behaviour manifesting in the same way and raising the same risk of sudden death during or following restraint became known to arise also from the misuse of drink, and/or related to certain health conditions, both physical and mental. Leading pathologists and other healthcare professionals advised the police service to adopt the wider umbrella term of ABD.” Source location 2017-0205-Response-by-Metropolitan-Police
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20 Mar 2015 Kingsley Burrell · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Lack of national training and understanding of how best to treat acute behavioural disturbance 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
Kingsley Burrell · 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
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
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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 national training and understanding of how best to treat acute behavioural disturbance
Wider context from the report “(1) Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behaviour disturbance. As a result he continued to struggle against restraint. Patients with this condition are at risk of death through prolonged restraint and struggle against restraint. Most training in relation to restraint deaths focuses on positional asphyxia. Position in this case was not a major consideration. It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance . Minimising the period of restraint is key. West Midlands Police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it . I suggest contact is made with Chief Inspector Russell at WMP for full information on the changes made in the West Midlands area.
” Source location Kingsley Burrell · 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 Examine the role, legal basis, responsibility and safe practice for police involvement in mental health restraint through an expert reference group.
Verbatim wording from the response “In this tragic case, police officers were called in to a mental health environment to effect restraint upon a patient. Aside from the moral and ethical issues pertaining to police officers entering into a care environment to affect this type of force, I am examining the whole issue of the role of police in these types of circumstances and indeed whether this is simply an issue of a lack of capability, capacity and training for health practitioners rather than that it is and should be presumed a police matter. I hope you will be reassured to know that to this end I have been working with the College of Policing and have instigated an expert reference group, chaired by Lord Alex Carlile, to ascertain not only the legal platform upon which activities should sit, but further who should effect them and what is defined as safe practice across all public service disciplines.” Source location 2015-0472-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National police forces had already received guidance and training addressing acute behavioural disorder risks, with overall compliance considered to meet the standard.
Verbatim wording from the response “Whilst it is helpful that West Midlands have cited their activity in respect of positional asphyxia and other risks associated with restraint, it is not accurate to suggest that the force has implemented safe practice independent of all forces nationally. Indeed, Acute Behavioural Disorder (ABD) and Excited Delirium were specifically highlighted in a 2010 Guidance Document issued by the former National Policing Improvement Agency (now renamed The College of Policing). The NPIA then ran a series of national events throughout 2010/2011 where every single force in the country was briefed and provided with training materials to address this specific set of risks.” Source location 2015-0472-Response-by-Metropolitan-Police
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23 Sep 2013 Michael James SWEENEY · Prevention of Future Deaths report London North (Inner)
View report summary
Concerns raised 1
Lack of shared recognition of the term “excited delirium” across emergency services 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
Michael James SWEENEY · 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
Michael James Sweeney died after taking cocaine and becoming extremely agitated; he was transported to hospital by police after an ambulance was not sent within the target time. He was restrained prone until sedation was effective, then arrested and died less than two hours later. The principal concerns were the inconsistent use and understanding of the term “excited delirium”, the risk of missing other medical causes of extreme agitation, and ambulance-service prioritisation of such emergencies.
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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 shared recognition of the term “excited delirium” across emergency services
Wider context from the report “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country , and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011 .
It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.
Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis. Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma.
From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause.
1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”.
2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now.
3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service.
4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately.
” Source location Michael James SWEENEY · 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 Adopt Acute Behavioural Disorder as the common terminology for the relevant medical emergency.
Verbatim wording from the response “Secondly, both national and Metropolitan Police training on the correct terminology to use have in fact already moved on since the date of this incident. Though the ‘constellation of behaviours’ has at various points in the developing knowledge about it’s causes and effects been known (inter alia) as ‘cocaine psychosis’, and ‘excited delirium’, since 2010 the generally recognised phrase within UK police texts has been ‘Acute Behavioural Disorder’ (‘ABD’). This phrase was chosen to provide exactly the “ ‘precision without ‘diagnosis’ “ you indicated would be a necessary element of any common terminology adopted. Inspector ████████ provides the practitioner’s context:” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Acute Behavioural Disorder content in officers’ regular Officer Safety and Emergency Life Support training, including refresher training.
Verbatim wording from the response “The generic term Acute Behaviour Disorder was selected as the most appropriate term and ABD was subsequently fast-tracked into the National Personal Safety Manual. The Faculty of Forensic and Legal Medicine also adopted the terminology of ABD, and have produced guidance on the management of this condition. The medical implications of the manual's techniques and guidance (including ABD) were reviewed by Professor ████████ in 2010. Furthermore, additional improvements were most recently made to the ABD advice by Professor ████████ in 2012, following Rule 43 advice in another case.” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct Central Communications Command staff to identify relevant calls in messages to the ambulance service and provide supporting training on awareness and procedures.
Verbatim wording from the response “These moves to enhance staff awareness of the condition and the terminology of ABD to describe it, undertaken by our partners in the LAS, have been mirrored in steps undertaken within our own call-handling centre, the Central Communications Command (CCC). On the 20th September 2013, Chief Inspector Horwood issued the following practice direction to all Central Communications Command Staff:” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the joint MPS–LAS Memorandum of Understanding containing documented call-handling guidance and communication arrangements for suspected Acute Behavioural Disorder.
Verbatim wording from the response “Point 4 above is of course a matter for the London Ambulance Service. I understand they will be replying to you separately on this. I would anticipate however that they will in that response make reference to the adoption of a new Memorandum of Understanding between our respective services, on providing ‘...guidance on joint working including use of CAD Link and Joint Response Units’, which we are now in the final stages of completing.” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage NHS partners to adopt Acute Behavioural Disorder terminology and increase supporting awareness of the condition.
Verbatim wording from the response “The potential information gap for MPS civil staff working at Central Communications Command who do not receive this training routinely has been addressed by the issuing of direct practice notes, and supported by a programme of in-house training on awareness of the issues and correct procedures to adopt. Meanwhile, the development of a detailed and documented joint agency call-handling protocol with our partners at London Ambulance Service, contained within the new Memorandum of Understanding, gives both ‘First Responder’ agencies a common wellspring of guidance to draw upon, a robust channel of communication where ABD is suspected, and clarity regarding the expectations each agency can have of the other’s response in these circumstances. It is now important that staff in emergency departments are also made aware of this condition and its management.” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Educate staff and communicate terminology covering acute behavioural disturbance and excited delirium.
Verbatim wording from the response “The LAS alongside our colleagues in the Police Services in London currently use the term acute behavioural disturbance (ABD) to describe the clinical manifestation of disturbed behavior, which is often associated with recreational drug use and / or some aspects of mental health. The term is described by the Faculty of Forensic and Legal Medicine of the Royal College of Physicians (England) in their helpful guidelines paper dealing with the recognition and treatment of this clinical presentation¹. It is from these guidelines, produced by this leading clinical authority on the subject, that the LAS have taken the view that the term “acute behavioural disturbance” (ABD) is appropriate to describe this group of patients and have used this term in the education of our staff.” Source location 2013-0236-Response-by-London-Ambulance-Service
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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 Upgrade police-originated calls involving acute behavioural disturbance, cocaine toxicity or physical restraint to the highest response category.
Verbatim wording from the response “In essence, it is the use of the word “acute” that is felt to be key. Since April 2013 the LAS has been upgrading the triage category (to our highest level of response) of calls from the police where there is information which notes the patient is suffering from acute behavioural disturbance, cocaine toxicity, or is being physically restrained.” Source location 2013-0236-Response-by-London-Ambulance-Service
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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 Raise terminology and guidance issues through the national Ambulance Service Mental Health Working Group for review.
Verbatim wording from the response “excited delirium, which specifically relates to police incapacitant devices (TASERS). We have raised this issue through the national Ambulance Service Mental Health Working Group, asking them to look both at the appropriate terminology and guidance around the subject matter itself. The national Ambulance Service Mental Health Working Group has confirmed that they will issue a position statement about the use of an appropriate term following a response to their proposal from the Royal College of Psychiatrists.” Source location 2013-0236-Response-by-London-Ambulance-Service
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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 Share the response with the Pan-London Emergency Department Consultants Group to disseminate the term acute behavioural disturbance.
Verbatim wording from the response “We recognise that the evidence you heard was that some Emergency Department staff were not familiar with the term ABD and as such we will share this response with the Pan-London Emergency Department Consultants Group in order to disseminate the use of the term ABD to the Emergency Departments in London.” Source location 2013-0236-Response-by-London-Ambulance-Service
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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 Acute Behavioural Disorder training makes additional police training changes on terminology and recognising the medical emergency unnecessary.
Verbatim wording from the response “Your recommendation regarding a common terminology has been accepted by all partners. It is respectfully submitted however that the adoption by the London Ambulance Service of the term ‘Acute Behavioural Disorder’ as the term of choice effectively negates the additional training changes recommended in points 1 and 2 of your report, as active training on ABD and responses to it remain an ongoing element in all regular refresher training sessions for police officers, and this, we are given to understand, is now being paralleled within the LAS via their own training and practice direction regimes.” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The term “extremely agitated” does not adequately describe this presentation and may not prompt an appropriate timely response.
Verbatim wording from the response “On 18th October 2013 at the meeting of the Metropolitan Police Clinical Advisory Group, there was consensus that the term ABD was already in common use by paramedics, Emergency Medical Technicians, police officers and the forensic clinicians. The Group has senior medical and clinical representation from the LAS, the Metropolitan Police Forensic Medical Services, and the Education and Training Departments of both organisations. The group’s view was that to re-educate our staff on the use of a different term would be challenging, and may well present a greater risk by using terminology that the pre hospital multi-disciplinary team may not be familiar with. It was felt that the term “extremely agitated” does not adequately describe this particular clinical presentation, is open to wide interpretation, and would not prompt the appropriate timely response.” Source location 2013-0236-Response-by-London-Ambulance-Service
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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 Protocols and training will not change to adopt the recommended terminology unless and until it accords with national ambulance-service guidance.
Verbatim wording from the response “The London Ambulance Service NHS Trust (the LAS) remains of the view that ‘acute behavioural disturbance’ is the term that most accurately reflects the presentations of this group of patients as well as being recognised by the appropriate bodies and we do not consider that the recommendation can be agreed unless / until the change in terminology accords with national guidance for UK ambulance services.” Source location 2013-0236-Response-by-London-Ambulance-Service
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Includes failures in controls specifically dedicated to recognising, communicating, triaging or responding to acute behavioural disturbance, including control-room, frontline, prison, ambulance, mental-health and forensic-medical training; accurate ABD guidance and terminology; formal competence assurance; recognition of ABD as a medical emergency; appropriate restraint or containment safeguards; emergency escalation and clinical response.
