PFD report

Matthew William Lewis · Prevention of Future Deaths report

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Issued 13 Feb 2019•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to provide clear and consistent rescue instructions in hanging episodes
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 recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Amend contact-management learning standards within one month to emphasize preservation of life and suitable public rescue instructions.

    Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.
  2. Action

    Circulate a summary of the issue to heads of contact management across England and Wales to support clarification of locally delivered training.

    Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.
  3. Action

    Develop force procedures providing hanging-incident guidance for call handlers and incorporate that guidance into their training.

    Stated by South Wales PoliceStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide clear and consistent rescue instructions in hanging episodes

Wider context from the report

“(1) Both ████████ in their evidence expressed confusion as to the instructions that were passed to them by the call handler. In particular, whether they should approach Mr Lewis and attempt to cut him down or refrain from doing so in the interests of scene preservation (2) The subsequent evidence of the Officer in Charge, ████████ was to the effect that his primary role as a police officer was the preservation of life. The initial instructions of the Call handler here appeared inconsistent with that expressed overriding duty. (3) In any hanging episode, time is very much of the essence following suspension. Whilst it could be determined on the evidence the exact time that that occurred on 27.2.18, medical evidence received at the Inquest indicated that death/irreversible brain injury would likely occur, no later than 5 minutes post suspension. With such a narrow “rescue window”, the clarity of instructions to willing rescuers appears paramount. Whilst it was found on the evidence that the actions of the call handler were neither directly, nor indirectly causative of Mr Lewis’ death, there is a risk that in the future, a repeat of confusing/inconsistent call handler instructions may lead to delay & potentially contribute to the prospects of an unsuccessful rescue. (4) Guidance/training for call handlers as to how to deal with such scenarios would seem desirable/mandated ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Amend contact-management learning standards within one month to emphasize preservation of life and suitable public rescue instructions.

Verbatim wording from the response

“The College of Policing produces the National Policing Curriculum which sets the learning standards for a number of key areas of policing including contact management which informs the training of police call handlers and dispatchers. In doing so we work closely with the National Police Chiefs Council lead for this area, currently Assistant Chief Constable (ACC) ████████ from the Police Service of Northern Ireland. In response to this report we will, within the next month, amend the learning standards for contact management staff to reflect that the preservation of life is paramount when considering the impact on scene preservation and that suitable instructions should be given to willing members of the public who are able to assist in preserving life and providing rescue where possible.”

Source location

2019-0048-Response-by-College-of-Policing
Page 1 · response
Published 24 May 2019

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Circulate a summary of the issue to heads of contact management across England and Wales to support clarification of locally delivered training.

Verbatim wording from the response

“I have also asked that a summary of this issue is circulated, via ████████ to all heads of contact management across England and Wales so that they can take any necessary urgent action in respect of clarifying locally delivered training.”

Source location

2019-0048-Response-by-College-of-Policing
Page 1 · response
Published 24 May 2019

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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

Develop force procedures providing hanging-incident guidance for call handlers and incorporate that guidance into their training.

Verbatim wording from the response

“In addition, whilst there is no national guidance for this type of circumstance issued by the College of Policing to Call Handlers in Police Forces, South Wales Police has taken steps to develop a procedure for call handlers, which incorporates appropriate guidance into its force procedures. The new procedure is incorporated into training that call handlers receive and in particular, the paragraph below that highlights the presumption that ‘life is not extinct’.”

Source location

2019-0048-Response-by-South-Wales-Police
Page 2 · response
Published 24 May 2019

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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

Maintain trainer or experienced-operator monitoring and rapid intervention for new and inexperienced call handlers.

Verbatim wording from the response

“South Wales Police invest considerably in training call handlers to deal with a multitude of situations; however, a training scenario can never replicate the experience gained from with real incidents. In respect of this, I can confirm that South Wales Police have a procedure in place for new and inexperienced call handlers, where a trainer or more experienced operator monitors and is able to step in very quickly when the new operator is unsure of the advice they should be giving.”

Source location

2019-0048-Response-by-South-Wales-Police
Page 2 · response
Published 24 May 2019

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026