Recurring concern

Failure to ensure police officers consult infrequently used operational guidance

Get email alerts

Request correction

First reported 9 Jul 2019•Latest report 15 Dec 2022

Definition

What this concern includes

Includes failures of police controls intended to ensure officers access, consult or are prompted to review infrequently used operational guidance or SOPs when relevant, including guidance-checking expectations, reminders, accessibility and assurance that guidance has been consulted.

Not included

Excludes deficiencies in the substantive content of police guidance where the concern is not failure to consult or check it.
Excludes generic police training, staffing or workload deficiencies unless they directly cause failure to consult relevant infrequently used operational guidance.
Excludes failures involving routine or frequently used guidance unless the assertion specifically concerns the same infrequently used-guidance checking process.
Excludes clinical, ambulance or non-police guidance processes unless the report explicitly concerns police officers' use of operational guidance.

Reports: 2
Individual concerns: 2
Date range: 2019–2022
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

College of Policing2

Thames Valley Police2

Association of Ambulance Chief Executives1

National Police Chiefs’ Council1

South Central Ambulance Service NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

15 Dec2022
Berkshire
Concerns raised1
1. Lack of checking of infrequently used guidance
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.
Respondent positions 2
1. Position
  Mandating periodic review of all infrequently used guidance is impracticable because of the volume of guidance materials.
  Stated by Thames Valley PoliceUnable to act
1. Position
  Existing briefing, training and guidance communication mechanisms address identified risks without requiring universal periodic guidance review.
  Stated by Thames Valley PoliceExisting arrangements considered sufficient
AI-generated summary

Neal Terence Saunders · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of checking of infrequently used guidance
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
Page 3 · concerns
Open source report
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 periodic review of all infrequently used guidance is impracticable because of the volume of guidance materials.

Verbatim wording from the response
“7. Checking of guidance which is infrequently used”

Source location
Response from Thames Valley Police
Page 7 · response
Published 19 December 2022
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
Existing briefing, training and guidance communication mechanisms address identified risks without requiring universal periodic guidance review.

Verbatim wording from the response
“• In response to the Reg. 28 section which states ‘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’, we have considered whether it would be practicable to mandate officers to periodically review what amounts to 282 SNAP Guides, 222 Operational Guidance notes, and APP covering a 24 areas. Given the high volume of this guidance, this has not been deemed practicable.”

Source location
Response from Thames Valley Police
Page 7 · response
Published 19 December 2022
Open published response
9 Jul2019
Berkshire
Concerns raised1
1. Failure to encourage officers to consult infrequently used SOPs and guidance
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.
Actions described in response 1
1. Action
  Introduce Local Police Area points of contact to communicate new guidance and encourage staff review.
  Stated by Thames Valley PoliceStated completed
AI-generated summary

Leroy Dacosta Junior Medford · 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

Leroy Dacosta Junior Medford, referred to as Junior, was arrested by Thames Valley Police on 1 April 2017 and detained under the drugs SOP after being suspected of concealing drugs. His condition deteriorated in his cell, and resuscitation was unsuccessful; the recorded cause of death was heroin (diamorphine) toxicity. The principal concerns were that officers of all ranks involved did not know that the SOP required observation from inside the cell, and broader concerns about how police training is delivered, monitored, prioritised and taken up.

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
Failure to encourage officers to consult infrequently used SOPs and guidance
Wider context from the report
“Concern Regarding Future Training My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police. We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe. That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line. I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly. This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review. It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently. ”
Source location
Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce Local Police Area points of contact to communicate new guidance and encourage staff review.

Verbatim wording from the response
“It is accepted that TVP have had challenges to communicate with all front line staff to ensure they are aware of guidance and update themselves on it, especially when they are performing an unfamiliar role. To counter this the Policing Strategy Unit have introduced Special Points of Contact or ‘SPOCs’ from within the team on each Local Police Area so they can build relationships with local staff. This will assist with communications locally when new guidance is produced so staff are aware of its existence and are encouraged to review it.”

Source location
2019-0233-Response-by-Thames-Valley-Police
Page 5 · response
Published 13 September 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of checking of infrequently used guidance

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to encourage officers to consult infrequently used SOPs and guidance

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.1

Respondent positions 2

Actions described in response 1