PFD report

Rashan Jermaine CHARLES · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 29 Jun 2018•Inner North London

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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to recognise that apparent resistance may indicate a struggle to breathe
    Part of recurring concern: Failure to recognise breathing emergencies during police encounters
  2. Lack of specific training advice on managing public assistance
  3. Choking without classic visible signs
    Part of recurring concern: Failure to recognise breathing emergencies during police encountersPart of recurring concern: Unsafe implementation of choking-risk prevention measures
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

    Train officers to manage bystander assistance through practical scenarios and situation-specific decisions using the National Decision Model.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.
  2. Action

    Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.
  3. Action

    Provide recruit and three-yearly refresher training on recognising and treating choking, including cases without classic signs.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    It is not possible to prescribe how bystanders should be used because situations, backgrounds, training and skills vary.

    Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 recognise that apparent resistance may indicate a struggle to breathe

Wider context from the report

“When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers. 1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that. 2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick. 3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.) 4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed. Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment. I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers. ”

Is this part of a recurring concern?

Yes — Failure to recognise breathing emergencies during police encounters.

Open source report

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

Lack of specific training advice on managing public assistance

Wider context from the report

“When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers. 1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that. 2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick. 3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.) 4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed. Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment. I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Choking without classic visible signs

Wider context from the report

“When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers. 1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that. 2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick. 3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.) 4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed. Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment. I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers. ”

Is this part of a recurring concern?

Yes — Failure to recognise breathing emergencies during police encounters; Unsafe implementation of choking-risk prevention measures.

Open source report

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

Difficulty assessing whether breathing is present and normal

Wider context from the report

“When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers. 1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that. 2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick. 3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.) 4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed. Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate. Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment. I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of whether a person is breathing.

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

Train officers to manage bystander assistance through practical scenarios and situation-specific decisions using the National Decision Model.

Verbatim wording from the response

“The potential value of bystanders in dealing with casualties is recognised within the training given to officers and is explored with various scenarios. These include assisting in placing a subject into the spinal recovery position, crash helmet removal and the delivery of CPR.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 4 · response
Published 14 August 2018

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

Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.

Verbatim wording from the response

“The importance of completing a thorough breathing check and regularly monitoring a subject’s breathing is central to ELS training. The training states that if breathing cannot be established because a subject is in the recovery position, they should be turned onto their back to facilitate a full breathing check. It further states that CPR should be commenced if there is any doubt.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 3 · response
Published 14 August 2018

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

Provide recruit and three-yearly refresher training on recognising and treating choking, including cases without classic signs.

Verbatim wording from the response

“The Programme Specification states in respect of choking: “An airway obstruction can be recognised by difficulty speaking, attempts to breathe or cough, increasing signs of asphyxia (blueness discolouration to face) and eventual loss of consciousness. Therefore, it is therefore made clear that individuals who are choking they may not be able to breathe or cough.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 3 · response
Published 14 August 2018

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Deliver ELS training scenarios requiring officers to assess breathing, reposition subjects, recognise noisy breathing and provide CPR.

Verbatim wording from the response

“The careful assessment of a subject’s breathing features in one of the training scenarios within the 2018 / 2019 ELS training package. The scenario requires an assessment of a subject’s breathing, and them being re-positioned to assist breathing. The scenario then develops to noisy breathing and onto the delivery of cardiopulmonary resuscitation (CPR).”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018

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

It is not possible to prescribe how bystanders should be used because situations, backgrounds, training and skills vary.

Verbatim wording from the response

“The potential value of bystanders in dealing with casualties is recognised within the training given to officers and is explored with various scenarios. These include assisting in placing a subject into the spinal recovery position, crash helmet removal and the delivery of CPR.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 4 · response
Published 14 August 2018

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 MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.

Verbatim wording from the response

“The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Share the findings supporting revised restraint guidance with the College of Policing.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 14 August 2018.
  2. 2

    Require officers to tilt a subject’s head forward when possible to reduce airway obstruction during management of concealed items.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.
  3. 3

    Continue reviewing and refining first-aid techniques and practices through a leading role in national police first-aid work.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2018.

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 findings supporting revised restraint guidance with the College of Policing.

Verbatim wording from the response

“The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018

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

Require officers to tilt a subject’s head forward when possible to reduce airway obstruction during management of concealed items.

Verbatim wording from the response

“The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 2 · response
Published 14 August 2018

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

Continue reviewing and refining first-aid techniques and practices through a leading role in national police first-aid work.

Verbatim wording from the response

“First aid training of MPS officers is the remit of MPS Senior First Aid Advisor, ████████ ████████ is also Chair of the National Police First Aid Forum. The MPS continues to have a leading role in the review and refinement of existing techniques and practices and acknowledges that this remains a continual learning process.”

Source location

2018-0210-Response-by-Metropolitan-Police
Page 5 · response
Published 14 August 2018

Open published response
Back to top

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